GUIDELINES FOR THE MANAGEMENT OF ALCOHOL WITHDRAWAL IN THE ACUTE GENERAL HOSPITAL SETTING
Matthew Cowan Consultant Gastroenterologist April 2013
This document contains recommendations for the management of patients at risk of alcohol withdrawal admitted to Surrey and Sussex Healthcare NHS Trust. These guidelines have been formulated in collaboration with the Departments for Digestive Diseases, General Medicine, Emergency Department and Pharmacy. These guidelines have been agreed by the Medical Department Meeting and acknowledged by the Trust Management Board for Quality and Risk. These guidelines will be reviewed in April 2015.
Guidelines for the management of acute alcohol withdrawal
EXECUTIVE SUMMARY • Harmful alcohol use costs the NHS approximately £2.7 billion, 78% of which is
incurred in secondary care. Patients with physical dependence upon alcohol are at risk of developing symptomatic alcohol withdrawal syndrome following admission. The most severe form of alcohol withdrawal syndrome, delirium tremens carries a mortality of 15-20% if unrecognised and untreated. • These guidelines refer to the management of drinkers who require admission
for the management of medical illness, or who present to the Emergency Department with established alcohol withdrawal syndrome. Patients who wish for elective alcohol detoxification will be managed by the Drug and Alcohol Services outside of the general hospital setting. • All patients who are admitted to SaSH under General Medicine or
Gastroenterology will be screened for alcohol misuse with the Modified Single Alcohol Questionnaire (M-SASQ). • Patients who score positive on the M-SASQ will be assessed for risk of
alcohol withdrawal syndrome by the admitting doctor and referred to the Drug and Alcohol Service for ongoing support if required. • Patients at risk who are admitted to the Acute Medical Unit or Charlwood
Ward will be monitored for signs of alcohol withdrawal syndrome with the modified Clinical Institute Withdrawal Assessment (CIWA; Appendix 1). A score above 12, or two scores of 9 will trigger a fixed dose alcohol withdrawal regimen (Appendix 2). Patients who do not develop symptoms of alcohol withdrawal after 72 hours are no longer at risk and monitoring can be discontinued. • Patients at risk of alcohol withdrawal syndrome admitted to other clinical areas
will receive a fixed dose alcohol withdrawal regimen (Appendix 2). • Recommended dosing schedules for a five day chlordiazepoxide reducing
dose alcohol withdrawal regime are provided (Appendix 2). • Separate guidelines for the management of patients at risk of alcohol
withdrawal presenting to the Emergency Department with unrelated problems exist. A subgroup with mild symptoms of alcohol withdrawal may be admitted to CDU for 24 hour observation with the modified CIWA; those who develop severe symptoms necessitating pharmacological treatment of withdrawal will be admitted under the General Medical take. • Pharmacological alcohol withdrawal regimens must be completed prior to
discharge. Benzodiazepines for alcohol withdrawal will not be provided by pharmacy to ward patients after discharge. • All patients at risk of alcohol withdrawal must receive vitamin B
supplementation as prophylaxis of Wernicke-Korsakoff Syndrome. 1
Guidelines for the management of acute alcohol withdrawal DRAFT
CONTENTS 1. Introduction and definitions
3
1.1 Introduction
3
1.2 The alcohol withdrawal syndrome [AWS]
4
1.3 Scope of guidelines
7
2. Screening for alcohol dependency
7
2.1 Introduction
7
2.2 The Modified Single Alcohol Screening Question (M-SASQ)
8
3. Management of patients at risk of alcohol withdrawal syndrome
10
3.1 General measures
10
3.2 Treatment of common symptoms during alcohol withdrawal
10
3.3 Prophylaxis of Wernicke’s encephalopathy
11
3.4 Pharmacological interventions for prevention of AWS
12
3.5 Prescribing Regimen – Delirium Tremens
13
3.6 Discharge Planning and Aftercare
13
4. Symptom-triggered approach to AWS
13
4.1 Introduction
13
4.2 Modified Clinical Institute Withdrawal Assessment for Alcohol (CIWA)
14
5. Fixed dose alcohol withdrawal regimens
15
Appendix 1 Symptom-triggered alcohol withdrawal
16
Appendix 2. Fixed dose alcohol withdrawal regimens
18
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Guidelines for the management of acute alcohol withdrawal
1. Introduction and definitions 1.1 Introduction The estimated cost of alcohol misuse on the UK economy is £25.1 billion, including £2.7 billion in costs to the NHS, over 78% of which is incurred as hospital based care (Department of Health, 2008). In England, 23% of the adult population consumes alcohol in a hazardous or harmful way, and the prevalence of alcohol dependence has increased from 1.1 million adults in 2000 to 1.6 million in 2009 (6% of men and 2% of women)(McManus et al., 2009). Alcohol related hospital admissions have doubled in the last 8 years to over 1 million per annum. The Department of Health made reducing alcohol related admissions a Public Service Agreement target for the NHS in 2008, and this has been carried forward into the Public Health and NHS Outcomes frameworks for England as a key indicator in England (DH, 2012). ·
It is estimated that 24% of adults drink in a hazardous or harmful way in the UK
·
Hazardous and harmful drinking is are commonly encountered among people attending hospital for illnesses unrelated to alcohol
·
20% of people admitted to hospital for illnesses unrelated to alcohol are drinking at hazardous or harmful levels [Nice 100]
·
4% of the adult population are estimated to be drinking dependently [Nice 115]
The Department of Health recently revised the way in which it describes drinking behaviours: ‘hazardous drinkers’ are now described as being at increased risk and ‘Harmful drinkers’ are now described as being at high risk. Because of the extensive use of the terms hazardous and harmful drinking within literature, the World Health Organization International Classification of Disease [10th revision] and many of the tools recommended within these guidelines; it is thought useful for clarify to retain the terms hazardous and harmful drinking. Sensible Drinking (Lower Risk) Sensible drinking is drinking in a way that is unlikely to cause yourself or others significant risk of harm. Hazardous Drinking (Increasing Risk) A pattern of drinking alcohol consumption that increases someone’s risk of harm this includes: Binge Drinking Binge drinking is essentially drinking too much alcohol over a short period of time and it is typically leads to drunkenness. It has immediate and short-term risks to the drinker and to those around them. People who become drunk are much more likely to be involved in an accident, assault, be charged with a criminal offence, contract a sexually transmitted disease and, for women, are more likely to have an unplanned pregnancy. It is defined 3
Guidelines for the management of acute alcohol withdrawal DRAFT
by measuring those drinking over 6 units a day for women or over 8 units a day for men. Harmful Drinking (High Risk) Harmful drinking is drinking at levels that lead to significant harm to physical and mental health and at levels that may be causing substantial harm to others. Examples include liver damage or cirrhosis, dependence on alcohol and substantial stress or aggression in the family. Women who regularly drink over 6 units a day (or over 35 units a week) and men who regularly drink over 8 units a day (or 50 units a week) are at highest risk of such alcohol-related harm. Dependent Drinking (Alcohol Dependence) A cluster of behavioural, cognitive and physiological phenomena that may develop after repeated alcohol use. Typically, these phenomena include a strong desire to drink, impaired control over its use, persistent use despite harmful consequences, a higher priority given to alcohol use than to other obligations, increased tolerance, and a physical withdrawal reaction when alcohol is discontinued. In ICD-I0, the diagnosis of dependence syndrome is made if three or more of six specified criteria were experienced within a year. 1.2 The alcohol withdrawal syndrome [AWS] Alcohol withdrawal syndrome is the clinical syndrome that occurs when people who are physically dependent upon drinking stop drinking or reduce their alcohol consumption. [Burns, 2004] Not all heavy drinkers will experience withdrawal phenomena and the 40% that do develop acute alcohol withdrawal syndrome will present with a wide range of severity of withdrawal symptoms and in some cases withdrawal may be life-threatening. The AWS can therefore be grouped into four sets of symptoms. Group 1: Uncomplicated alcohol withdrawal Occur within hours [typically 6-8 hours] of last drink and may develop before the blood alcohol level has fallen to zero. Commonly peaking at 10-30 hours and usually subsiding by 40 to 50 hours [Adinoff 1988, DTB,1991, Hall,1997, Morgan [1998] • Signs and symptoms of autonomic arousal Sweating Tachycardia [100+bpm] Raised BP Fever [37-38+ C] Hyperreflexia ·
Characteristic tremor, starting in the hands but progressing to the head and trunk as severity worsens. 4
Guidelines for the management of acute alcohol withdrawal
·
Anxiety, restlessness, irritability, depression, insomnia and tiredness
·
Anorexia, nausea, and weakness.
·
Confusion
Group 2: Hallucinosis ·
Onset in the majority of cases is within 24 hours of last drink, stopping within another 24-48 hours
·
Both auditory [frequently accusatory or derogatory voices] and visual [bugs crawling on the bed, for example] hallucinations occur in otherwise clear sensorium.
• This is unlike delirium tremens where sensorium is diffused and
impaired. (Chick,2000, Rubino,1992, Turner, 1998) Group 3: Alcohol related seizures ·
Can occur at 6 to 48 hours of alcohol cessation are more likely if there is a previous history of withdrawal fits or epilepsy. Fits are rare beyond 48 hours following cessation. [Morgan, 1998]
·
They are characterised by major motor seizures that occur during withdrawal in patients who normally have no seizures and have normal EEGs. Fits tend to be single, generalised (if focal, suspect head injury) and may occur in bouts.
·
30% of cases are followed by DTs.
Group 4: Delirium tremens (DTs) ·
Delirium tremens is the most severe manifestation of alcohol withdrawal. DTs occur in only about 5% of patients undergoing alcohol withdrawal but account for the highest morbidity and mortality.
·
Onset of DTs is 2 to 5 days [most commonly at 2 to 3 days] following cessation and represents a medical emergency. [Adinoff,1988, Erwin, 1998, CRAG 1994, Morgan, 1998, Rubino,1992]
DT’s usually occur in heavy drinkers who have ·
Minimised their consumption
·
Or withdrawn unexpectedly,
•
Been inadequately treated during withdrawal.
•
Patients consuming more than 16 units per day (½ to a bottle of spirits per day or equivalent) are particularly at risk.
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Guidelines for the management of acute alcohol withdrawal DRAFT
In addition to the classical symptoms of withdrawal the characteristic symptoms of DT’s are: ·
Agitation, apprehension, confusion, disorientation in time and place, visual and auditory hallucinations, insomnia, nausea, vomiting, motor inco-ordination and paranoid ideation may be present.
·
Fever is common.
·
Poor concentration, intermittent disorientation and agitation may continue for 1-2 weeks before recovery.
Risk Factors for Progression to Severe Withdrawal: There is a risk of progression to severe withdrawal symptoms and delirium tremens if the patient with mild symptoms also have associated ‘risk factors’ [Chick,1989, DBT,1991, CRAG,1994, RCP,2001] ·
high alcohol intake > 15 units per day in a person of normal build, previous history of severe withdrawal, seizures and/or DTs
·
Concomitant use of other psychotropic drugs, high levels of anxiety, other psychiatric disorders.
·
Poor physical health, hypoglycaemia, hypokalaemia [with respiratory alkalosis, hypocalcaemia]
·
Fever, sweating, insomnia, tachycardia
·
Poor nutritional state
·
high alcohol intake > 15 units per day in a person of normal build, previous history of severe withdrawal, seizures and/or DTs
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Guidelines for the management of acute alcohol withdrawal
Patients suffering alcohol withdrawal require regular risk assessments depending on the severity of their withdrawal. 1.3 Scope of guidelines These guidelines refer only to patients at risk of alcohol withdrawal syndrome who require admission to SaSH for the management of medical symptoms or conditions, or who present with established alcohol withdrawal. Elective admission of dependent drinkers for the purposes of detoxification will continue to be managed by the Drug and Alcohol Service. Separate guidelines on the management of alcohol withdrawal and intoxication in patients presenting to the Emergency Department are already in place. General recommendations regarding admission of patients with alcohol withdrawal: • Alcohol withdrawal syndrome is a medical emergency that can result in death. All patients presenting with established severe withdrawal symptoms should be admitted. • Patients with mild withdrawal symptoms (defined as modified CIWA scare 612) who present to the Emergency Department may be admitted to the Clinical Decisions Unit for 24 hour observation. Those who improve will be discharged. Patients who develop severe withdrawal (modified CIWA >12 or two scores >9) will be admitted under General Medicine for treatment. • Patients at risk of alcohol withdrawal who do not require admission as a result of their presenting illness but who do not have symptoms of alcohol withdrawal should be discharged with advice that sudden discontinuation of alcohol intake can be hazardous. This should be documented in the Discharge Summary with a recommendation that the GP refer to appropriate community support services. 2. Screening for alcohol dependency 2.1 Introduction For effective early detection, NHS professionals should routinely carry out alcohol screening on every patient as an integral part of practice. As 90% of adults consume alcohol it must be assumed that most people who attend healthcare settings do consume alcohol. Recent studies in primary care and in accident and emergency departments identify that the majority of patients approached are willing to participate in alcohol screening research. Furthermore, users of healthcare services are becoming more familiar with professionals enquiring about personal lifestyle behaviours. It is recommended that all patients admitted under General Medicine or Gastroenterology are screened for hazardous drinking with the abbreviated MSASQ. Perhaps the best introduction that legitimises questions on alcohol can be adapted from the following; 7
Guidelines for the management of acute alcohol withdrawal DRAFT
“…because alcohol use can affect your health and can interfere with certain medications and treatments, it is important that we ask some questions about your use of alcohol. Your answers will remain confidential so please be honest...” 2.2 The Modified Single Alcohol Screening Question (M-SASQ) Finding time to screen for alcohol problems in a busy clinical setting using the gold standard that is AUDIT is challenging; particularly when faced with acute and unplanned admissions. The use of the Single Alcohol Screening Question (SASQ) (Williams & Vinson, 2001; Canagasaby & Vinson, 2005) is a validated solution to screening for all alcohol use disorders in challenging settings.
Fill in with the patient and
only one box
If the patient's response is 'Monthly', 'Weekly' or 'Daily or almost daily' the score is MSASQ positive. If the result is positive provide feedback on what a positive test result means and provide an information leaflet and contact information on where to get further help. All individuals who are identified as experiencing an Alcohol Use Disorder using the MSASQ (i.e. Hazardous/Harmful or Dependent drinking) should receive: ·
Feedback on what a positive test means, “1 in 4 alcohol adults in England drink excessively placing them at increased risk of various health conditions such as, liver disease, depression, accidents and various cancers. Your score on this test suggests you are drinking at similar levels and you need to reduce your level of alcohol use. If you find this hard to do we would suggest you contact your GP or a local service in your area to assist you”
·
Issue the patient with a leaflet which describes the risks associated with excessive drinking
·
Advice on where to get further help if the patient is not being retained in the service. This will include primary care and voluntary agencies that can conduct further assessment and advice, as well as agencies that provide support (e.g. GP, Addaction,CRI, Respond,Shot, AA, National drink helpline, etc)
·
Offer further assessment for alcohol withdrawal if the patient is to be admitted as the positive screen may indicate risk of alcohol withdrawal symptoms.
Utilising the MSASQ will identify those individuals who have an alcohol use 8
Guidelines for the management of acute alcohol withdrawal
disorder. If these individuals are not admitted provision should be made so that they can access further alcohol assessment. It is recommended that if the patient is an outpatient further assessments can be accessed by specialist agencies and primary care teams experienced in providing triage assessment. The flowchart below summarises this process.
Those admitted may experience either hazardous/harmful or dependent drinking. As the MSASQ does not discriminate between these disorders further assessment is required. Those who are dependent may experience alcohol withdrawal across a continuum of severity. The severity of alcohol withdrawal is significantly influenced by; the level of consumption that is regularly used, time since last drink, body weight, gender, malnutrition, pre-existing physical and mental health problems, etc. As the onset of severe alcohol withdrawal can be rapid those who are MSASQ positive (i.e. Monthly, Weekly or more) require assessment of withdrawal from alcohol upon admission to any unit/ward. Withdrawal assessment should aim to: a) identify those individuals who need an assisted withdrawal because of alcohol dependence b) identify: · the severity of the dependence · the level of alcohol consumption c) determine the urgency with which the assisted withdrawal should be provided d) facilitate further assessment of treatment needs It is advised that these patients receive a short clinical interview that includes: · When did the patient have the last drink? · Consumption in units of alcohol per day/week? · Drinking pattern daily/continuous or episodic/binge drinking? 9
Guidelines for the management of acute alcohol withdrawal DRAFT
·
·
·
Is there a history of withdrawal symptoms (e.g. sweating, tremor, nausea, vomiting, anxiety, insomnia, seizures, hallucinations or delirium tremens) ? Is there a history of morning/relief drinking, change in tolerance, strong compulsion to drink, continued drinking despite problems, priority of drinking over other important pursuits/activities? (all indicative of dependence syndrome) History of alcohol related problems (medical, psychiatric, social, relationship, occupational, financial, legal etc)
3. Management of patients at risk of alcohol withdrawal syndrome 3.1 General measures All patients at risk of alcohol withdrawal require close observation and monitoring of vital signs, correction of dehydration or electrolyte imbalance and treatment of concurrent conditions e.g. infection, hypoglycemia, hepatic failure, gastrointestinal bleeding etc. Patients should be orientated, reassured that any distressing symptoms will settle, Patients given an explanation of their symptoms and their relationship to excessive consumption. Any patient suffering alcohol withdrawal has the potential to develop seizures and delirium tremens [DTs]. If DTs are not detected early or managed effectively, then there is a high risk of the patient becoming aggressive and violent towards members of staff. Therefore the risk management plan for patients suffering alcohol withdrawal should reflect this risk element. Best practice dictates that the following general measures should be put in place:- [Ghodse, 2002] • Ensure adequate levels of medical and nursing staff – This may require additional staff for 1-1 or 2-1 nursing. • Ensure Nursing observations & CIWA are carried out regulary and medication
is given as prescribed regulary and PRN • Treat the patient in a well lit area away from other patients – if possible a side room • Keep external stimuli, especially noise, to a minimum • Use a friendly, understanding but firm approach • Be aware of the possibility of withdrawal fits 3.2 Treatment of common symptoms during alcohol withdrawal Many of these symptoms are normal in withdrawal. Reassure the patient they will improve during detoxification. Avoid unnecessary pharmacological treatment and only treat if severe withdrawal symptoms become more severe after this then the patient should be reassessed medically.
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Guidelines for the management of acute alcohol withdrawal
Symptom
Possible Treatment
Sleep difficulties: Sleep hygiene Do not prescribe hypnotics If severe consider loading the total daily dose of chlordiazepoxide towards the evening or increasing nightime dose for 1-2 days or extending the period of detoxification Poor appetite
Encourage diet. If severe nutritional and vitamin supplements
Nausea
Metoclopramide 10 mg oral or intramuscular
Diarrhoea
If severe loperamide 2-4 mgs prn
Heartburn
Gaviscon 10 ml prn
Itching
Check for signs of liver disease. necessary chlorpheniramine 2-4 mg tds
Headache
Paracetamol with caution in severe liver disease
Anxiety
Very common in withdrawal, usually resolves after 3-4 days. May unmask pre-existing anxiety which will need assessing in its own right
Depression
Very common. Monitor for severe persistent symptoms and suicidal ideation. Treat if necessary if symptoms persist beyond four weeks post withdrawal.
3.3 Prophylaxis of Wernicke’s encephalopathy Most patients admitted for inpatient care will be more severely alcohol dependent than those treated in a community setting. Hence inpatients are at greater risk of complications e.g. withdrawal seizures, Wernicke ’s encephalopathy (confusion, ataxia, ophthalmoplegia) etc. The following sign/symptoms occurring during alcohol withdrawal should be taken as indication of a presumptive diagnosis of Wernicke's encephalopathy and must be treated immediately with parenteral thiamine (absorption of oral thiamine is inadequate): · Confusion (not due to intoxication) · Memory disturbance · Ophthalmoplegia (paralysis of eye muscles) · Hypothermia (low body temperature) · Hypotension (low blood pressure) · Coma/unconsciousness (not due to intoxication) In addition parenteral thiamine should be used in the following circumstances: · Alcohol withdrawal fits · Delirium tremens · Patients who are malnourished or obviously physically unwell 11
Guidelines for the management of acute alcohol withdrawal DRAFT
Acute peripheral neuritis (inflammation of the nerves) Dosage of thiamine: ·
Prophylaxis: One pair high potency ampoules of Pabrinex IV daily for 5 days (all moderate/high risk patients should receive this as a minimum) Treatment: · Two pairs high potency ampoules of Pabrinex IV daily for a minimum of 3-5 days THEN · If improvement one pair of ampoules daily for 5 days · If no improvement discontinue treatment For patients with; enduring ataxia, polyneuritis, memory disturbance: · One pair of ampoules daily for as long as improvement continues Anaphylaxis is a rare but recognised complication. Anaphylactic and serious allergic reactions are more severe and more frequent with the intravenous route. If given IV Pabrinex should be diluted in 50-100mls of normal saline or 5% dextrose and given over 15-30 minutes. Facilities for treating anaphylactic reactions must be readily available whenever parenteral thiamine is used. Intravenous dextrose should not be given before Pabrinex due to risk of precipitating Wernicke’s encephalopathy. 3.4 Pharmacological interventions for prevention of AWS NICE clinical guidelines 100 and 115 recommend pharmacotherapy delivered via fixed and symptom-triggered protocols for assisted alcohol withdrawal. Alcohol dependent patients exhibiting or at risk of developing withdrawal (based on their previous history) should be prescribed a benzodiazepine, usually chlordiazepoxide. Dosage should be individually titrated against severity of withdrawal symptoms, however the close relationship between Typical Days Drinking, Severity of Alcohol Dependence appears to indicate severity of alcohol withdrawal symptoms and medication required to manage symptoms. Ultimately this is a matter of clinical judgement. NOTE: In managing acute alcohol withdrawal, the use of oral benzodiazepines (Chlordiazepoxide) is standard practice. There are occasions when the oral administration route is impractical and alternative routes of administration such as IM or IV are utilised, i.e. a patient in acute alcohol withdrawal showing signs of delirium refuses oral medication. Patients occasionally require rapid tranquilisation to prevent further physical deterioration and / or prevent aggressive or violent behaviour, which places the patient, staff and fellow patients at risk. Some patients may remain symptomatic despite prolonged (i.e. >24 hours) benzodiazepine treatment. The diagnosis of alcohol withdrawal should be reviewed. Look for other causes (ie benzodiazepine dependency, drug seeking 12
Guidelines for the management of acute alcohol withdrawal
behaviour, organic agitation as part of delirium or other cause). Discontinue detoxification, consider other drug treatment strategies and if necessary investigate further. 3.5 Prescribing Regimen – Delirium Tremens Management of the severely confused/agitated patient involves administration of adequate sedative doses of benzodiazepines [intravenously if necessarily]. The object of the treatment is to make the patient calm and sedated but easily roused • Patient requiring parenteral treatment, prescribe IV diazepam emulsion 10 mgs every 30 – 60 minutes [should be given at a rate of not more than 5mgs per minute into a large vein]. Avoid IM diazepam, but rectal diazepam may be useful. • For patient with liver failure, prescribe IV lorazepam up to 0.5 to 1mgs every thirty minutes [may also be given IM] • Severe psychotic symptoms may be managed by the addition of haloperidol 1mg to 5 mg 2-3 times a day, although adequate treatment with benzodiazepines is the priority. • Give high dose parenteral thiamine •
Maximum doses of chlordiazepoxide may be needed for 36-48 hours
3.6 Discharge Planning and Aftercare Well in advance of discharge a plan for further support in the community should be prepared with the patient's full participation and with the involvement of relevant community agencies. The clinical team need to ensure the following procedures have been completed: •
Referral to the Alcohol Liaison Nurse Specialist if available on site
•
All patients must have completed their chlordiazepoxide regime before discharge. Pharmacy will not dispense medication for prevention of alcohol withdrawal as TTO.
•
Prescription for Vitamins i.e. Thiamine 100mgs TDS, Vitamin B Co Strong x 2 for 2 weeks TTO
•
Information on community support services available
4. Symptom-triggered approach to AWS 4.1 Introduction 13
Guidelines for the management of acute alcohol withdrawal DRAFT
Approximately 60% of patients at risk of alcohol withdrawal will not manifest symptoms of AWS. It is extremely unusual for symptoms to develop greater than 72 hours after cessation of drinking. upon stopping or significantly reducing alcohol intake. Symptom-triggered detoxification is an alternative to the fixeddose treatment strategy in standard use currently. Duration of detoxification may be reduced but significantly more monitoring of withdrawal symptoms is required. Symptom-triggered detoxification should be considered for all patients at risk of AWS admitted to a clinical area where nursing and medical staff have been appropriately trained. In practice it is assumed that this will be the A&E, Clinical Decision Unit, Acute Medical Unit or Charlwood Ward. Patients should not be transferred to alternative wards, without a valid clinical reason, unless a fixed dose withdrawal regimen is triggered (see below) or they are deemed to be no longer at risk of AWS. If a patient transfer is necessary, a fixed dose withdrawal regimen should be prescribed. The protocol for symptom-triggered withdrawal is summarised in Appendix 1. 4.2 Modified Clinical Institute Withdrawal Assessment for Alcohol (CIWA) The Modified CIWA scale is used to assess alcohol withdrawal symptoms with a view to appropriate management of patients who are undergoing a symptomtriggered assisted alcohol withdrawal programme (detox). This objective rating scale is a standardised clinical assessment in which various features are scored to give a numerical index of severity [Gross, 1973]. The assessment takes approximately 5 minutes and covers psychological changes, changes in arousal level and perceptual changes of alcohol withdrawal. The higher the score, the more the symptoms and signs present which suggests the greater risk of complications i.e. seizures, confusion and hallucinations. A protocol for the Modified CIWA is given in Appendix 1. A trained nurse should assess all alcohol dependent patients using the Modified CIWA on admission to the ward and thereafter: • Hourly for first 4 hours • Repeat 4 hourly for scores < 6 • Monitoring can be discontinued after 72 hours if stable
A score greater than 6 is considered significant. High scores should trigger a response: • If the score is greater than 6 the measure should be repeated after 2 hours • If the score is greater than 9 the measure should be repeated after 1 hour • One score of 12 or two scores of 9 indicate the need for benzodiazepines. In
this case it is recommended that a fixed dose withdrawal regimen is prescribed and formal monitoring of CIWA can be discontinued. 14
Guidelines for the management of acute alcohol withdrawal
5. Fixed dose alcohol withdrawal regimens The fixed regimen should be used in all wards other than A&E, Clinical Decision Unit, Acute Medical Unit and Charlwood Ward or if staff are not available to carry out intensive assessment needed for the symptom triggered approach. Three suggested regimens are given depending upon the average daily alcohol intake in units. Additional breakthrough doses of chlordiazepoxide 20 mg may be required if there are breakthrough withdrawal symptoms and with delirium tremens. If more than one additional dose of chlordiazepoxide is required within a 24 hour period the fixed dose regimen should be increased. All suggested regimens are for 5 days; a longer period of detoxification may be required if the patient has required high doses, additional doses or has experienced severe withdrawal symptoms or delirium tremens. Details of the fixed dose regimens and protocols for their use are given in Appendix 2.
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Guidelines for the management of acute alcohol withdrawal DRAFT
Appendix 1 Symptom-triggered alcohol withdrawal
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Guidelines for the management of acute alcohol withdrawal
Alcohol Withdrawal Assessment Flow Sheet
Name MRN
Date Temperature
Pulse
Respiration rate Tremor (Arms extended, fingers spread)
Sweating (Observation)
Clouding of sensorium (“What day is this? What is this place?”)
Quality of contact
Agitation (Your observation)
Time 0) 37.0-37.5°C 1) 37.6-38.0°C 2) Greater than 38.0°C 0) 90-95 1) 96-100 2) 101-105 3) 106-110 4) 111-120 5) Greater than 120 1) 20-24 2) Greater than 24 0) No tremor 2) Not visible—can be felt fingertip to fingertip 4) Moderate with arms extended 6) Severe even with arms not extended 0) No sweat visible 2) Barely perceptible, palms moist 4) Beads of sweat visible 6) Drenching sweats 0) Orientated 2) Disorientated for date by no more than two days 3) Disorientated for date 4) Disorientated for place (re-orientate if necessary) 0) In contact with examiner 2) Seems in contact, but is oblivious to environment 4) Periodically becomes detached 6) Makes no contact with examiner 0) Normal activity 2) Somewhat more than normal activity 4) Moderately fidgety and restless 6) Pacing, or thrashing about constantly
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Guidelines for the management of acute alcohol withdrawal DRAFT 0) No disturbance Thought 2)Does not have disturbance much control over (Flightcontrol of ideas, over nature of own paranoia) thoughts
Visual disturbances (Photophobia, hallucinations)
4)Constantly troubled by unpleasant thoughts 6)Thoughts come too rapidly and in disconnected fashion 0) Not present 2)Mild sensitivity (bothered by the lights) 4)Intermittent visual hallucinations 6)Continuous visual hallucinations
Total Score
·
Hourly for first 4 hours for all alcohol dependent patients
·
Repeat 4 hourly for scores < 6 – discontinue after 72 hours if stable
·
Repeat Hourly for scores > 9 and two hourly for score > 6
·
One score of 12 or two scores of 9 indicate need for benzodiazepines (Bleep doctor to prescribe fixed dose chlordiazepoxide regimen)
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Guidelines for the management of acute alcohol withdrawal
Appendix 2. Fixed dose alcohol withdrawal regimens
19
