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Alcohol Withdrawal and Delirium in the Intensive Care Unit

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Alcohol Withdrawal and Delirium in the Intensive Care Unit Netherlands Journal of Critical Care Copyright © 2012, Nederlandse Vereniging voor Intensive Care. All Rights Reserved. Received April 2011; accepted February 2012 REVIEW Alcohol withdrawal and delirium in the intensive care unit M Paupers*, A Schiemann*, CD Spies * Marco Paupers and Alexander Schiemann contributed equally to this article Universitätsklinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité -Universitätsmedizin Berlin, Berlin, Germany Abstract - In intensive care patients, delirium triggered by alcohol withdrawal is underestimated despite the fact that it occurs in approximately 10% of all ICU patients. Alcohol withdrawal delirium is the most serious manifestation of alcohol withdrawal and it is associated with even more complications and poor outcome. Therefore, it should be prevented; if it does occur it should be treated as early as possible to avoid negative sequelae, in particular infections, cardiac complications and long-term cognitive dysfunction. In this article we summarize strategies to detect alcohol use disorders and alcohol withdrawal and those for treating alcoholic withdrawal and delirium tremens. Keywords - ICU, withdrawal, alcohol, delirium, alcohol withdrawal syndrome (AWS) Introduction This article gives an overview on how to reduce and treat this Besides nicotine, alcohol is the most abused drug worldwide [1- potentially life-threatening complication [18] in critically ill patients 4]. About one-fifth of the patients seen in clinical practice present with an underlying AUD. with an alcohol use disorder (AUD) [2,5]. The prevalence of AUD, i.e. alcohol abuse or harmful use and alcohol dependence Alcohol use disorders among patients undergoing surgical or diagnostic procedures Alcohol use disorders (AUD) include a wide range of drinking is seen in approximately 20% of cases and nearly half of the behaviours from hazardous use of alcohol to alcohol abuse, surgical patients with AUD have alcohol dependence [6]. Alcohol- harmful consumption, and alcohol dependence. dependent patients usually present alcohol withdrawal after Hazardous use means exceeding a daily alcohol intake of surgery [7]. 60g per day (g alcohol equals mL of drunken alcohol times % In ICU patients, delirium triggered by alcohol withdrawal is of alcohol included in beverage x 0.8). 60g/d of ethanol means a frequent complication and seen in approximately 10% of all three to four bottles of beer and ¾ of a bottle of wine, respectively. ICU patients. The incidence of postoperative delirium (POD) in This is associated with a higher rate of complications and a poor patients with AUD can reach 50% if not prevented. Effective outcome [8,19,20]. This cut-off is not related to dependency but prevention halves the incidence of POD in patients and - if not it determines the complication threshold for patients undergoing prevented - reduces its severity [8-10]. surgical or interventional procedures. Delirium independent of different etiologies is seen in up to Alcohol abuse is included in the Diagnostic and Statistical 82% of ICU patients and is associated with poor outcome [11]. Manual of Mental Disorders, 4th edition, Text Revision (DSM IV-TR) Its presence in ICU patients is an independent predictor of an [21] and harmful use is included in the International Classification increased duration of mechanical ventilation, length of ICU and of Diseases (ICD-10) criteria [22], not fulfilling the dependence hospital stay [11-14] and overall elevated hospital costs [11,15]. criteria. Moreover, duration of delirium is associated with an increased risk of one-year mortality and in cases of survival, cognitive Alcohol dependence dysfunction [16,17]. Therefore, it is crucial for the clinician to Approximately 10% of all hospitalized patients can be diagnosed as prevent and detect this serious complication early on in order alcohol-dependent [6,23]. Patients with alcohol dependence show to avoid consequences that lead to elevated morbidity and the highest risk of all patients with AUD for severe complications mortality [11]. Evidence suggests that in those patients for whom such as delirium, infection, sepsis, septic shock, postoperative appropriate care and immediate treatment is provided, mortality haemorrhage and long-term cognitive dysfunction [8,16,24-28]. can be reduced [7]. Alcohol dependence have similar DSM IV-TR [21] and ICD- 10 criteria [22]. The ICD-10 diagnosis of alcohol dependence is given if at least three out of six dependence criteria have been Correspondence present together at some time during the last 12 months. DSM-IV- TR requires at least three out of seven symptoms occurring at any CD Spies time in the last 12 months for the diagnosis of alcohol dependence. E-Mail: [email protected] 84 NETH J CRIT CARE - VOLUME 16 - NO 3 - JUNE 2012 Netherlands Journal of Critical Care Alcohol withdrawal and delirium in the intensive care unit Identification of AUD patients eight or more points reveals hazardous or harmful alcohol use Screening patients for AUD is the precondition to taking preventive (ICD-10) [33]. measures and improving outcome as well as reducing the length Neumann et al. showed a lower cut-off for women (men eight of hospital stay (LOS). Prevention should be started as early as points and women five points) of the AUDIT in an interactive possible to shorten or even avoid ICU treatment [6]. Alcohol- computerized lifestyle assessment including the AUDIT [33]. related questionnaires enable validated scores to be obtained for screening. These scores can either be used as paper-pencil as well as computerized self-evaluation [2]. Table 2. AUDIT-Test: Alcohol-Use Disorder Identification Test The computer-based AUDIT [30] self-assessment showed in a study significantly higher AUD detection rates than the AUDIT-TEST: ALCOHOL-USE DISORDER Identification TEST preoperative assessment by anaesthesiologists [2]. The use of How often do you have a drink (0) never self-report questionnaires such as AUDIT with high sensitivity is containing alcohol? (1) once per month or less recommended for AUD screening [31]. Martin et al. described an (2) 2-4 times per month (3) 2-3 times per week increase of the detection rate of AUD in clinical routine if patients (4) 4 times or more per week are visited more than once - from 16% after one visit to 34% after How many drinks containing alcohol (0) 1-2 a third visit [32]. do you have on a typical day when you (1) 3-4 are drinking? (2) 5-6 (3) 7-9 Alcohol-related questionnaires (4) 10 or more Alcohol-related questionnaires are the basic tools for identifying How often do you have six or more (0) never patients with AUD. The most commonly used is the Alcohol Use drinks on a occasion? (1) less than monthly Disorder Identification Test (AUDIT). (2) monthly (3) weekly (4) daily or almost daily AUDIT How often during the last year have (0) never The Alcohol Use Disorder Identification Test (AUDIT) developed you found that you were not able to (1) less than monthly by the World Health Organization (WHO) consists of ten questions stop drinking once you had started? (2) monthly with a score ranging from zero to 40 points. An overall score of (3) weekly (4) daily or almost daily How often have you failed to do what (0) never Criteria for diagnosis of alcohol dependence Table 1. was normally expected from you (1) less than monthly because of drinking? (2) monthly (3) weekly (4) daily or almost daily DIAGNOSTIC AND Statistical International Classification How often have you needed a first (0) never MANUAL (DSM-IV-TR) OF DISEASES (ICD10) drink in the morning to get yourself (1) less than monthly Tolerance to alcohol Tolerance to alcohol going after a heavy drinking session? (2) monthly (3) weekly Withdrawal syndrome Withdrawal syndrome (4) daily or almost daily Continued alcohol use despite Continued alcohol use despite How often during the last year have (0) never physical or psychological clear evidence of harmful you had a feeling of guilt or remorse (1) less than monthly problems consequences after drinking? (2) monthly Neglect of important social, Neglect of pleasures or interests, (3) weekly occupational, or recreational increased amount of time (4) daily or almost daily activities because of alcohol use necessary to obtain or take the How often during the last year have (0) never substance or to recover from its you been unable to remember what (1) less than monthly effects happened the night before because (2) monthly Persistent desire to use alcohol or Strong desire or compulsion to you have been drinking? (3) weekly unsuccessful efforts to cut down use alcohol (4) daily or almost daily or control alcohol use Have you or someone else been (0) no alcohol is used in larger amounts Inability to control alcohol use injured as a result of your drinking? (2) yes, before last year or over a longer period than (4) yes, in the last year intended Large proportion of time is spent Has a relative or friend, or a doctor or (0) no in activities necessary to obtain other health worker been concerned (2) yes, before last year alcohol, use alcohol, or recover about your drinking or suggested you (4) yes, in the last year from its effects to cut down? (Diagnosis of alcohol dependence: ICD-10: ≥3 symptoms of dependence An overall AUDIT score ≥ 8 reveals any AUD (hazardous or harmful alcohol present together at some time during the last 12 months; DSM-IV-TR: ≥3 use or dependence). symptoms of dependence occurring at any time in the last 12 months) (AUD: ≥8; No AUD: <8) Modified from references [21,22,29]. Adapted from references [30] and [37]. NETH J CRIT CARE - VOLUME 16 - NO 3 - JUNE 2012 85 Netherlands Journal of Critical Care M Paupers, A Schiemann, CD Spies Table 3. CIWA-Ar SCALE Bush et al. published a short version of the AUDIT (AUDIT C) REVISED CLINICAL INSTITUTE Withdrawal ASSESSMENT FOR ALCOHOL as a brief screening tool to detect heavy drinking, active alcohol SCALE (CIWA-AR) abuse or dependence [34].
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