Acute Care Management of Alcohol Withdrawal Objectives
At the end of this presentation, the learner will be able to:
1. Explain the pathophysiology of alcohol withdrawal. 2. Describe the assessment of a patient’s risk for alcohol withdrawal using the PAWSS score. 3. Describe the use of the Alcohol Withdrawal Orders including: monitoring of the patient, doses of medications, and CIWA-Ar scale.
3/10/2020 2 Alcohol Withdrawal Orders
The alcohol withdrawal order set guides the medical management of alcohol withdrawal so that complications such as delirium tremens, seizures or cardiac dysrhythmias can be avoided. When it is used appropriately it helps to maintain patient safety and comfort.
3/10/2020 3 Facts
9.6% of the population in the U.S. are alcoholics. It is estimated that 1 out of 5 hospitalized patients abuses alcohol. Approximately 25% of patients withdrawing from alcohol have seizures, usually within 24 hours after drinking has stopped.
3/10/2020 4 Pathophysiology Alcohol and the Brain
Alcohol use affects the two major neurotransmitters, GABA and glutamate. GABA (у-aminobutyric acid) allows chloride into the brain cell and has a natural calming or sedative effect. Alcohol will take over this function and allow more chloride into the brain cell causing increased sedation.
3/10/2020 5 Pathophysiology Alcohol and the Brain
Glutamate is an excitatory (NMDA) neurotransmitter which would normally increase brain activity and energy levels. Alcohol suppresses the release of glutamate, causing increased sedation.
3/10/2020 6 Pathophysiology Alcohol and the Brain
Chronic alcohol use causes the brain cells to stop responding or have little response to GABA. Alcohol may be the only substance that is allowing chloride into the neuron. Chronic alcohol use also causes the cell to up-regulate (make more of) the receptor sites in an attempt to get more glutamate.
3/10/2020 7 Pathophysiology Alcohol Withdrawal
During withdrawal, the neurons no longer have alcohol to allow chloride into the cell for its sedative effect. This is a stimulus. The brain cells have up-regulated and are taking in larger amounts of the excitatory glutamate and alcohol is not there to inhibit the glutamate. This is a stimulus.
3/10/2020 8 Pathophysiology Alcohol Withdrawal
The lack of chloride and the excess glutamate cause brain hyperexcitability which can be seen as: anxiety, HTN, tremors, insomnia, irritability, hallucinations, palpitations, diaphoresis, headache, and GI upset.
3/10/2020 9 Pathophysiology Alcohol Withdrawal
Severe symptoms of the brain hyperexcitability that can occur with alcohol withdrawal include alcohol withdrawal seizures and delirium tremens. Seizures are more common if the patient has a history of multiple episodes of detoxification.
3/10/2020 10 Symptoms of Alcohol Withdrawal Syndrome
The symptoms of alcohol withdrawal will vary depending on the amount of alcohol intake and the extent of a patient’s recent drinking habits. Minor symptoms such as insomnia or anxiety may occur while the patient still has a positive blood alcohol level.
3/10/2020 11 Symptoms of Alcohol Withdrawal Syndrome Symptoms Time to symptoms after cessation of alcohol
Minor: insomnia, anxiety, 6 – 12 hours GI upset, HA, tremors, diaphoresis
Visual/auditory/tactile 12 – 24 hours hallucinations
3/10/2020 12 Symptoms of Alcohol Withdrawal Syndrome
Symptoms Time to symptoms after cessation of alcohol
Withdrawal seizures 24 – 48 hours
Withdrawal delirium (DTs) hallucinations, tachycardia, 48 – 72 hours HTN, low-grade fever, agitation, diaphoresis
3/10/2020 13 Complications of Alcohol Withdrawal
■ Seizures If the patient has a history of previous seizures during alcohol withdrawal, there is a 70% chance of recurrence of seizures each consecutive time that withdrawal occurs.
3/10/2020 14 Complications of Alcohol Withdrawal
■ Delirium Tremens (DT’s) Severe mental and neurological changes, including psychosis and seizures that typically occur within 72 hours after the last drink of alcohol. DTs are considered a life-threatening complication and are treated with life-support measures, anti-seizure medications, antihypertensive medications, and sedatives.
3/10/2020 15 Complications of Alcohol Withdrawal
The patient with a history of daily heavy alcohol use, DTs or withdrawal seizures, older age, abnormal liver function, and more severe withdrawal symptoms on admission is at higher risk for developing alcohol withdrawal delirium.
3/10/2020 16 Complications of Alcohol Withdrawal
■ Delirium Tremens (DT’s) The patient with DTs has a mortality rate of 1 - 5% and the use of the alcohol withdrawal protocol can help avoid DTs.
3/10/2020 17 Complication of Withdrawal Alcoholic Ketoacidosis
Alcoholic Ketoacidosis is an acute metabolic acidosis with a high anion gap* and elevated serum ketones. * Anion gap is calculated by subtracting the serum concentrations of chloride and bicarbonate from the sodium plus potassium concentrations. It is used to determine the possible cause of metabolic acidosis.
3/10/2020 18 Complication of Withdrawal Alcoholic Ketoacidosis
■ Ketoacidosis occurs because the patient does not eat and quickly exhausts any stored hepatic glycogen, so ketones are made by the liver as an energy supply. The serum glucose for the non-diabetic alcoholic is less than 150 mg/dL. Elevated ketones + normal serum glucose + high anion gap = alcoholic ketoacidosis.
3/10/2020 19 Complication of Withdrawal Alcoholic Ketoacidosis
Vomiting = dehydration* = reduced renal perfusion = limited urinary excretion of ketones and elevated serum ketones. Mortality is rare and morbidity often results from complications such as heart failure or pancreatitis. Often treated with IVF of D5NS so that the patient is receiving some glucose for energy. *The patient may also have metabolic alkalosis related to vomiting and dehydration.
3/10/2020 20 Complication of Withdrawal Wernicke-Korsakoff Syndrome
■ A degenerative brain disorder caused by the lack of thiamine (vitamin B1). The deficiency of thiamine occurs because the patient is in starvation mode or not eating properly. Alcohol also interrupts the normal metabolism of thiamine and contributes to the thiamine deficiency.
3/10/2020 21 Complication of Withdrawal Wernicke-Korsakoff Syndrome
Symptoms: confusion, stupor, coma, hypothermia, hypotension, gait abnormalities (ataxia), paralysis of certain eye muscles (ophthalmoplegia), and nystagmus (horizontal and vertical involuntary, rapid, rhythmic movements of the eyeballs).
3/10/2020 22 Complication of Withdrawal Wernicke-Korsakoff Syndrome
Treated by giving Thiamine 100 mg IV within the first 4 hours of admission. Memory function may improve slowly with treatment although it may never be completely restored.
3/10/2020 23 Nursing Responsibility
Nurses can determine the potential for alcohol withdrawal by use of physical assessment and communication skills by asking: How often does the patient drink alcohol How much alcohol does the patient drink Does the patient have any concerns about an alcohol or drug problem Has the patient ever experienced seizures or other symptoms during withdrawal
3/10/2020 24 Prediction of Alcohol Withdrawal Severity Scale (PAWSS)
3/10/2020 25 At risk drinkers as defined by the National Institute on Alcohol Abuse and Alcoholism
Men who drink more than five standard drinks* in a day are considered at risk drinkers. Women who drink more than four standard drinks in a day are considered at risk drinkers.
*Standard drink = 12 oz of beer or 5 oz of wine or 1.5 oz of 80-proof alcohol.
3/10/2020 26 Nursing Responsibilities
If the nurse believes the patient is at risk for alcohol abuse or there is a concern stated about the patients’ alcohol use, then further assessment is necessary. Social Work consult for alcohol abuse programs
3/10/2020 27 Risk factors for developing severe AWS • Previous episodes of alcohol withdrawal • Previous alcohol withdrawal seizures • History of delirium tremens • History of alcohol rehabilitation treatment • Previous episodes of blackouts • Concomitant use of CNS-depressant agents or illicit drugs • Recent alcohol intoxication • Blood Alcohol Level > 200mg/dL • Evidence of increased autonomic activity
3/10/2020 28 Alcohol Withdrawal Orders
See copy of orders. Ativan or Phenobarbital doses will be given based on CIWA-Ar score. Phenobarbital is a barbiturate that slows the activity of the brain and nervous system. It is used to treat or prevent seizures.
3/10/2020 29 Alcohol Withdrawal Orders
Benzodiazepines are medications that are proven to reduce the symptoms of alcohol withdrawal and decrease the risk of seizures and DTs. Lorazapam (Ativan) is a benzodiazepine that will increase GABA activity and reverse the effects of the alcohol withdrawal.
3/10/2020 30 Alcohol Withdrawal Orders
Patient is placed on pulse oximetry It is recommended that the patient is placed on telemetry monitoring at the time of the initial dose of a benzodiazepine and remains on telemetry until the withdrawal orders are discontinued.
3/10/2020 31 Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised CIWA-Ar
■ The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) is used to assess the patient. It provides 10 categories for physical and neurological symptoms of withdrawal.
■ The medication dosing is based on accurate CIWA-Ar scores and the CIWA-Ar score is confirmed by a trained nurse before Ativan or phenobarbital are given.
3/10/2020 32 Guidelines to CIWA-Ar Scores
Score <8 Monitoring only 0-8 Mild withdrawal symptoms 9-15 Moderate withdrawal symptom >15 Severe withdrawal symptoms and pending DT’s
Nurse assesses patient with CIWA-Ar scale per alcohol withdrawal orders, which ranges from every 15 minutes to every 4 hours. This is symptom-triggered therapy (medication given per symptoms) and has been shown to result in the use of less medication and shorter treatment times.
3/10/2020 33 Guidelines to CIWA-Ar Scores
3/10/2020 34 Guidelines to CIWA-Ar Scores
Principles Relieve symptoms Prevent seizures Prevent delirium tremens Prevent Wernicke’s encephalopathy 2 order set options for physicians Ativan order set Phenobarbital order set
3/10/2020 35 Benzodiazepines
Binds to the GABA-A receptor and produce an inhibitory effect similar to alcohol Has been considered first-line medication used to prevent seizures Rapid onset to control agitation Long action to control breakthrough symptoms Less dependence on hepatic metabolism to lower risk of over sedation May cause respiratory depression.
3/10/2020 36 Benzodiazepines
■ IV Ativan is a potential caustic agent and can damage the vein or cause burns at the injection site; assess the IV site of every 4 hours for signs of infiltration ■ The effects of the benzodiazepine must be evaluated and documented by the RN every 15 minutes to 1 hour per the alcohol withdrawal orders. ■ The assessment includes the sedation level and respiratory rate and depth and SpO2 level.
3/10/2020 37 Phenobarbital
Potentiates GABA-A receptors by enhancing binding of GABA to the receptor and through increasing the duration of GABA-A mediated inhibitory currents. Onset 5min, max effect 30min; half-life 53-140h. Administration: Slow IV injection, do not exceed 60mg/min, dilute in 10ml NS. Inject slowly to avoid severe respiratory depression, apnea, laryngospasm, hypertension or vasodilation. Over sedation and respiratory depression are possible side effects. NO ANTIDOTE!
3/10/2020 38 Factors That Can Affect CIWA-Ar Scores
Inconsistency of assessment and scoring A CIWA-Ar score must be done at the bedside by a RN who is educated and trained before benzodiazepines are given. If you are unsure about the score, it is best to have another nurse come to assess the patient with you.
3/10/2020 39 Factors That Can Affect CIWA-Ar Scores
Baseline diagnosis or chronic conditions may cause confusion during the assessment
The symptoms of anxiety or confusion may be related to a chronic condition such as hypoxia or dementia and erroneously assessed as a patient who is withdrawing. This may result in a patient who is given more of the benzodiazepine based on a higher CIWA-Ar instead of receiving the appropriate treatment for the underlying chronic condition or co-morbidity.
Be aware of the patient’s chronic conditions ! CIWA-Ar is not meant for meth or other drug withdrawal !
3/10/2020 40 Key Concepts of the Order Set:
GOAL: Quick control of the symptoms without over sedation *Keep patient sedation level at 0 to -2 using the RASS Sedation Scale GOAL: Keep the patient’s withdrawal symptoms consistently managed
3/10/2020 41 Sedation Scale Use Richmond Agitation Sedation Scale (RASS) to assess level of sedation when using drugs to chemically sedate a patient RASS Sedation Scale +4 = Combative – Violent -1 = Drowsy – Not fully alert (eye contact >10 sec) +3 = Very Agitated – Pulls at tubes -2 = Light Sedation – Briefly awake to voice +2 = Agitated – Nonpurposeful movement (eye contact < 10 sec) +1 = Restless – Anxious/apprehensive -3 = Moderate Sedation – Opens eyes to voice, 0 = Alert & calm but no eye contact -4 = Deep Sedation – Movement to physical stimulation only -5 = Unarousable – No response to voice/touch
RASS scale is found in the in the pain assessment section in EPIC Call MD if RASS score is -3 or lower and support patient respiratory status. Consider RRT.
3/10/2020 42 Medication Concepts
■ The effects of the benzodiazepine must be evaluated and documented by the RN every 15 minutes to 1 hour per the alcohol withdrawal orders. ■ The assessment includes the sedation level and respiratory rate and depth and SpO2 level.
3/10/2020 43 Medication concepts
■ Flumazenil (romazicon) is used to reverse sedation (RR < 10 or sedation level of < -3 caused by benzodiazepines Lorazapam (Ativan)
3/10/2020 44 Call Physician For:
Heart rate > 120; SBP > 160 or < 100; DBP >100 or < 60; RR > 30 or < 10; Temp > 38.5 Lethargy (RASS Sedation Score less than -3) Seizure Need for restraints Consider transfer to higher level of care
3/10/2020 45 Call Physician For:
Evaluation for transfer from Med/Surg to Stepdown/Progressive Care Unit CIWA-Ar severity score of 9 – 15 on more than 2 consecutive assessments Patient has more than 6 mg Ativan in 2 hours RASS -2 to -3 Evaluation for transfer to ICU Seizure activity CIWA-Ar score increase of more than 10 over previous measurement CIWA-A score exceeding 15 on 4 consecutive measurements Patient has required 14 mg or more of Ativan within 2 hours RASS -4 to -5
3/10/2020 46 Questions?
Adapted from: Poudre Valley Hospital Fort Collins, Colorado July 2007 Case Study # 1
A 43 year old male with a history of HTN and pancreatitis is admitted from the ED with a BAL (blood alcohol) of 1.2 (legally intoxicated = <0.8) He has abdominal pain and admitted to a medical unit. During the admission assessment, he reports that he drinks 1 pint of vodka every day. What additional information should you get?
3/10/2020 48 Case Study #1
Ask when the patient last had a drink of alcohol Ask if the patient has ever had seizures or any kind of difficulty when withdrawing from alcohol. Ask PAWSS questions What is your responsibility for this patient?
3/10/2020 49 Case Study #1
Call physician and report the patient’s condition, alcohol use, and last drink. Include information about seizures or DTs with previous ETOH withdrawal. Document patient’s responses as well as the call made to the physician and orders given. Consider Social Work consult for alcohol abuse resources.
3/10/2020 50 Case Study #1
The physician gave an order for the alcohol withdrawal protocol for this patient. Your assessment reveals that the patient has become increasingly agitated and diaphoretic with tremors. What action would you take at this time?
3/10/2020 51 Case Study #1
The charge nurse or designee and the primary RN who have been trained in using the alcohol withdrawal protocol will assess the patient and use the CIWA-Ar scale and concur on a score and administration of Lorazapam (Ativan).
What other orders and nursing care do you anticipate?
3/10/2020 52 Case Study #1
Place the patient on continuous pulse oximetry and telemetry. Give a dose of Ativan based on the Adult Alcohol Withdrawal order set and his CIWA-Ar score. Administer IV bag (1000 ml) with MVI, thiamine, and folic acid (banana bag) for 3 days. Assess CIWA as ordered by the severity level until less than or equal to 8. Discontinue CIWA assessments when less than 8 for 72 hours. Monitor VS, labs, I & O. Provide a supportive and quiet environment.
3/10/2020 53 Case Study #2
A 60 year-old female was admitted for pneumonia and received 1 mg Ativan for anxiety and slight agitation at 0600. At 0830, the MD orders the ETOH withdraw protocol based on her admission of daily alcohol use. She now has some nausea and no vomiting, a visible tremor in bilateral hands, she is barely sweating and seems anxious. She is restless, and c/o itching all over that feels like a burning sensation. She denies hearing or seeing things that she knows are not present. She has a HA of 5/10 and is oriented X 3.
3/10/2020 54 Case Study #2
What is her CIWA score?
3/10/2020 55 Case Study #2
CIWA- Ar score = 12 Remember to get a second assessment done by the charge nurse or peer who has been trained to perform a CIWA-Ar and two nurses will concur on the assessment of acute alcohol withdrawal symptoms and score before taking any additional action.
3/10/2020 56 Case Study #2
How much Ativan would you give?
3/10/2020 57 Case Study #2
She should receive 2 mg IV or PO Ativan. When do you reassess?
3/10/2020 58 Case Study #2
Reassess in 30 minutes RASS CIWA-Ar
CIWA-Ar is >8 Medicate again with Ativan 2 mg IV or PO Monitor every 30 minutes until CIWA-Ar is less than or equal to 8
3/10/2020 59 References
Alcohol. Retrieved January 3, 2007, from www.thebrain,mcgill.ca/flash/i/i_03/i_03_m/i_03_ m_par/i_03_m_par_alcool.htm Assessment and Identification Management of Alcohol Withdrawal Syndrome (AWS) in the Acute Care Setting. (October 2000). International Society of Psychiatric-Mental Health Nurses Position Paper.
3/10/2020 60 References
Bayard, M., McIntyre, J., Hill, K., & Woodside, J. (2004, March 15). Alcohol withdrawal syndrome. American Family Physician, 69(6), 1443-1450. McKay,A., Koranda, A., & Axen, D. (2004,February). Using a symptom-triggered approach to manage patients in acute alcohol withdrawal. Medsurg Nursing, 13(1), 15 – 20; 31.
3/10/2020 61 References
McKinley, M.G. (2005, June). Alcohol Withdrawal Syndrome. CriticalCareNurse, 25(3), 40 – 42, 44 – 48. O’Brien, M. & Alson, R. (2005, April 4). Alcoholic ketoacidosis. Retrieved December 19, 2005, from http://www.emedicine.com/emerg/topic21/htm
3/10/2020 62 References
Phillips,S., Haycock, C., & Boyle, D. (2006, Jul – Aug). Development of an Alcohol Withdrawal Protocol. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 20(4),190 – 198. Saitz, R. (2005, February 10). Unhealthy alcohol use. The New England Journal of Medicine, 352 (6), 596 – 607.
3/10/2020 63 References
Sullivan, J.T., Sykora, K., Schneiderman, J., Naranjo, C., & Sellers, E. (1989). Assessment of alcohol withdrawal: the revised clinical institiute withdrawal assessment for alcohol scale (CIWA- Ar). British Journal of Addiction, 84, 1353 – 1357.
3/10/2020 64 References
Elliott, Dolores Y. MSN, BSN, BA, RN, PMHCNS-BC; Geyer, Christopher BA, RN; Lionetti, Thomas MA, BSN, RN; Doty, Linda MSW, RN, PMHCNS-BC, CARN. (2012, April). Managing alcohol withdrawal in hospitalized patients. Nursing 2012: Volume 42, pg 22-30.
3/10/2020 65