1. 1. Dr SumitChandak Asst. Prof, Department of Psychiatry SKNMC & GH Management of Alcohol Withdrawal
2. 2. Objectives: Identifying an at risk patient. Assessment for severity of withdrawal in at risk patient. Complications of alcohol withdrawal and their assessment. Management of alcohol withdrawal and its complications.
3. 3. Identify at risk individuals:- Need to identify at risk individuals:- Low detection rates High rates of Mx/Sx complications when undetected
4. 4. Identifying an at risk patient : Elicit: History of alcohol/ substance use in all patients. Ask Pattern of use Duration of use Quantity of use Time since last drink May not be possible when acutely intoxicated acute trauma Then ask : friends family members Look for:- Smell of alcohol in the breath Features of withdrawal Tremors Tachycardia -BP Obtain blood alcohol level- if possible
5. 5. To identify potential problem drinkers: Use screening tool: CAGE questionnaire. C: Have you ever felt you should cut down on your drinking? A: Have people annoyed you by criticizing your drinking ? G: Have you ever felt bad or guilty about your drinking ? E: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye opener)?
6. 6. Assessment in at risk patient: Primarily for: factors predisposing to complications severity of withdrawal
7. 7. Assessment for predisposing factors: Metabolic disturbances: Hypoglycemia Lactic acidosis Ketoacidosis Na, Ca2+,Mg ed / ed K. ed Triglycerides Cardiac problems : most common Serious post op problems sec to: Risk of CAD ed cardiovascular stress sec to withdrawal G.I. problems: PUD Hepatitis Hematological monitoring: As alcohol suppresses bone marrow Presence of neurological factors
8. 8. For severity of withdrawal : Clinical monitoring intensively for first few days. For s/s of alcohol withdrawal Sx population : can use scales like CIWA-AI
9. 9. CIWA-Ar Clinical Institute withdrawal assessment of Alcohol scale , revised Observation on 10 parameters. Nausea and vomiting Tactile disturbances Tremor Auditory disturbance Paroxysmal sweats. Visual disturbances Anxiety
10. 10. CIWA-Ar Clinical Institute withdrawal assessment of Alcohol scale , revised Scores max possible: 67 Interpretation 6-7 mild withdrawal 8-14 : moderate withdrawal >15: severe withdrawal
11. 11. Complication of withdrawal state: Delirium: can occur anytime within 7days Seizures: usually around 3 day of last drink Other : Wernickes encephalopathy Psychosis Depression
12. 12. Delirium Definition: The hallmark symptom of delirium is an impairment of consciousness, usually accompanied by global impairments of cognitive functions; generally associated with emotional labiality, hallucinations or illusions, and inappropriate, impulsive, irrational, or violent behavior. Generally considered to be an acute reversible disorder but can become irreversible.
13. 13. Delirium Diagnostic criteria: A] Disturbance of consciousness (i.e. reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. B] A change in cognition (such as memory deficit , disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia .
14. 14. Delirium: Diagnostic criteria: C] The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. D] There is evidence from the history, physical examination, or laboratory findings of either (1) or (2): 1] The symptoms in Criteria A and B developed during substance intoxication. 2] Medication use is etiologically related to the disturbance.
15. 15. Delirium Assessment: Points to remember: fluctuating orientation Sequence of disorientation: T->PL->PE Sequence of re-orientation: PE->PL->T ASK for TIME: time/day/date/month/year PLACE: where are you/On what floor PERSON: Check for recognition of relatives/confabulation Cross check data with relative/attendant
16. 16. Management of alcohol withdrawal / risk patient: In at risk patient promote abstinence for at least 4 weeks of an elective pre-op procedure as it decreases morbidity from 74% -31% Modalities of Intervention: 1]Pharmacotherapy : Substitute Adjuvant 2] Counseling
17. 17. Pharmacotherapy: Substituent : Act on GABA receptors & mimic the action of alcohol: Lorazepam :poimiv Librium : po only Dosing depends on : severity of withdrawal presence of hepatic dysfunction altered neurological states 1st 24 hours: fixed dosing schedule flexible dosing schedule
18. 18. Pharmacotherapy Fixed dosing :Depending on the Quantity, Quality of alcohol and the time of last drink consumed. For Ex: Librium (10/25): 1-1-2 0-1-2 0-0-2 Lopez (2) : 2-2-2 1-1-2 Caution: Monitor Respiratory Rate
19. 19. Pharmacotherapy: Flexible dosing admission monitor fors/s of withdrawal : IF PRESENT: IF ABSENT: If present Give Librium (10) 2 stat Monitor 2 hourly If increased F/O withdrawal If decreased Continued monitoring 2 hourly If absent Monitor 4 hourly If present
20. 20. Pharmacotherapy Dose obtained at end of 24hours is the total dose required by that individual Continue on the same dose for 48 hours. Then taper by 20% every day every day, till eliminated.
21. 21. Pharmacotherapy: Adjuvant :For symptomatic control: 1] Propranolol 2]CBZ For metabolic parameters : Plenty of oral fluids Injection Thiamine/MVBC before any I.V. fluids especially containing sugar Tb Thiamine 75/100mg bid
22. 22. M/M of Delirium : Rule out other causes Lab: Se Electrolytes, BSL, LFT, RFT SOS: EEG M/M: Pharmacotherapy as above Restrain the patient Keep the lights on at night Frequently talk to & reorient the patients Correct electrolyte imbalance and underlying hepatic d/o if any When protracted - ECT
23. 23. THANK YOU
24. 24. DOS FOR DELIRIUM: Employ environmental interventions to reduce factors that may exacerbate delirium. These interventions include changing the lighting to cue day and night, reducing monotony and overstimulation and understimulation, correcting visual and auditory impairments (e.g., retrieve glasses, hearing aids), and rendering the patients environment less alien by having familiar people and objects present (e.g., family photographs).
25. 25. DOS FOR DELIRIUM Reorient the patient to person, place, time, and circumstances. Reorientation should be provided by all who come into contact with the patient. Provide reassurance to patients that the deficits they are experiencing are common but usually temporary and reversible.
26. 26. DONTS FOR DELIRIUM Unnecessarily restrain the patient Avoid Anticholinergics drugs like Phenergan in delirium especially alcohol withdrawal