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Alcohol Withdrawal Guideline - Intensive Care Unit

This policy outlines the guidelines for managing alcohol withdrawal in the Intensive Care Unit. It provides a comprehensive approach to identifying, assessing, and treating patients experiencing alcohol withdrawal symptoms to ensure their safety and well-being during this critical period.

Introduction and Purpose of the Guideline

The objective of this guideline is to provide a comprehensive approach for the early recognition and appropriate management of patients at risk for or experiencing alcohol withdrawal syndrome (AWS) in the Intensive Care Unita. Understanding the full clinical picture is crucial for effective patient care during this critical period. This guideline applies specifically to the ICU setting.

The purpose of this guideline is to facilitate the early recognition of patients at risk for AWS and implement appropriate strategies for their effective treatment. The key therapeutic goals include rapid control of symptoms with suitable therapy, guiding treatment using the Riker Sedation-Agitation Scale (SAS), and maintaining an SAS score of ≤ 4 through the titration of medications.

General Considerations

Contributing/Co-Existing Illness

Patients may have underlying conditions such as infection, pancreatitis, or recent surgery that can contribute to or exacerbate alcohol withdrawal symptoms.

Co-Morbid Illnesses

It's important to consider both medical and psychiatric diagnoses, including any risk of suicidality, when managing alcohol withdrawal in the ICU.

Symptom Progression

Closely monitor changes in the patient's condition during hospitalization, as alcohol withdrawal symptoms can progress rapidly.

Treatment Algorithms

This guideline outlines two distinct treatment algorithms to manage alcohol withdrawal in the ICU setting. The High-Risk Algorithm is designed for patients with severe withdrawal symptoms or those refractory to benzodiazepines. The Low-Risk Algorithm is for patients who do not meet the high-risk criteria.

Risk Assessment

Prediction of Alcohol Withdrawal Severity Scale (PAWSS)

The PAWSS is used to identify patients at risk for complicated AWS or delirium tremens. A score of 4 or higher indicates the need for aggressive treatment, as patients with mild symptoms may be harmed by unnecessary treatments.

PAWSS Scale

Exclusions from PAWSS

Patients with active severe withdrawal (refractory to benzodiazepines) and patients unable to understand or participate in the questionnaire (SAS ≤ 4) are excluded from the PAWSS assessment.

Low Risk Algorithm (PAWSS Less than 4)

All Patients

All Patients

High Risk Algorithm (PAWSS greater than or equal to 4 or active refractory withdrawal)

Non-Intubated Patients

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Intubated Patients

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Assessment Tools

1

Riker Sedation-Agitation Scale (SAS)

The SAS is used to assess the severity of active withdrawal. It provides accurate sedation and agitation assessment, unlike the CIWA which is not validated for ICU patients.

2

Usage of SAS

Regular assessments using the SAS are recommended for ICU patients to monitor their condition and guide treatment during alcohol withdrawal.

3

SAS Details

The complete SAS tool is provided below for reference.


Therapeutic Goals

Symptom Control

Using appropriate therapy guided by the Riker Sedation-Agitation Scale (SAS) and the clinical picture, the goal is to achieve rapid control of alcohol withdrawal symptoms and maintain an SAS score of ≤ 4.

Medication Titration

The treatment plan involves achieving initial control of symptoms and then re-dosing medications as needed to maintain the target SAS score of ≤ 4 throughout the patient's recovery.

Rapid Intervention

Prompt identification and treatment of alcohol withdrawal is crucial to avoid potential complications. The goal is to intervene early and effectively to ensure the patient's safety and well-being during this critical period.

Risk Factors for Sedation or Respiratory Compromise

Identified Risk Factors

  • Age over 60 years
  • Hepatic dysfunction (AST and ALT 2-3 times ULN)
  • Liver cirrhosis
  • Head injury
  • Recent administration of any opioids within past 6 hours
  • Pneumonia
  • Rib fractures
  • Chest tubes
  • Pulmonary contusions
  • Cervical collar or spinal brace

Consideration

These factors should guide the intensity and monitoring of sedation therapy to ensure the patient's safety and well-being during alcohol withdrawal in the ICU.

Routine Evaluation and Documentation

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2
3
1

Routine Use

Implementing the Riker Sedation-Agitation Scale (SAS) for regular assessment.

2

Documentation

Ensuring all evaluations and treatments are documented accurately.

3

Continuous Monitoring

Frequent reassessment to adjust treatment as needed.

Consistent use of the SAS tool is crucial for managing alcohol withdrawal in the ICU. Regular assessments allow the care team to closely monitor the patient's condition and make timely adjustments to the treatment plan. Detailed documentation of all evaluations and interventions is essential for providing high-quality, coordinated care.

Conclusion

This guideline provides a structured approach to managing alcohol withdrawal syndrome in the ICU, focusing on early recognition, risk assessment, and appropriate intervention. Key tools include the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) for risk assessment and the Riker Sedation-Agitation Scale (SAS) for ongoing monitoring and management. Understanding and addressing risk factors for sedation or respiratory compromise are critical in tailoring patient care.

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