out treating the underlying pathophysiology, thus increasing the risk of developing more severe withdrawal. They are also not ef-
fective when used alone for the treatment of withdrawal seizures or delirium (American Society of Addiction Medicine, 2020).
Managing complicated alcohol withdrawal Seizures
structured assessment scales such as the Confusion Assessment Method for ICU Patients (CAM-ICU) should be utilized. One-on- one observation should be initiated in patients who are agitated and disoriented. Restraints should be avoided unless necessary to prevent injury or comply with state laws (American Society of Addiction Medicine, 2020). Benzodiazepines are recommended as first-line treatment for al - cohol withdrawal delirium. Administration of intravenous benzo- diazepines to achieve a light sedation where the patient is awake but tends to fall asleep unless stimulated is recommended to help control agitation and maintain patient safety. High doses of ben- zodiazepines may be required to control agitation in patients with delirium as compared to other populations. Providers should not hesitate to use large doses but should monitor for oversedation and respiratory depression. Intermittent use of long- and short- acting benzodiazepines is recommended. Continuous IV infusion has not shown superiority over intermittent dosing and is typically more expensive. Patients should be monitored for signs of meta- bolic acidosis and hyponatremia (American Society of Addiction Medicine, 2020). Phenobarbital can be used as an alternative to benzodiazepines but is not preferred because of the need for close monitoring. Adjunctive antipsychotic agents can be used if delirium and hal- lucinations are not controlled by benzodiazepines. Antipsychotics should not be used as monotherapy because of the risk of lower- ing the seizure threshold and increasing the risk of withdrawal sei- zures. Second-generation antipsychotics such as risperidone and quetiapine are preferred because they have less of an effect on the seizure threshold when compared to first-generation agents. Haloperidol has also been successfully used in the management of delirium (American Society of Addiction Medicine, 2020). Self-Assessment Quiz Question #5 John begins to experience delirium symptoms while he is with - drawing from alcohol in the hospital and is admitted to the ICU. Which of the following is recommended as first-line therapy for the treatment of alcohol withdrawal delirium?
Patients who have experienced a seizure during their current with- drawal episode should be admitted to a setting that has close monitoring available for frequent reassessment every 1 to 2 hours for the first 6 to 24 hours. Electrolyte levels should be monitored to determine the need for IV fluids, and patients should be closely monitored for delirium. Safety measures such as fall precautions, frequent check-ins, and assistance with activities of daily living can also be implemented to ensure patient safety (American Society of Addiction Medicine, 2020). Treatment should be initiated immediately with a medication that is effective at seizure prevention. Parenteral administration through the intravenous route, or intramuscular if intravenous is unavailable, is preferred. Fast-acting benzodiazepines such as lo- razepam or diazepam are first-line treatments. When compared to placebo in a double-blind clinical trial of emergency department patients, intravenous lorazepam significantly reduced the risk of recurrent seizures. Phenobarbital can be used in patients who are unable to use benzodiazepines, but parenteral phenobarbital should only be given in intensive or critical care units because of the risk of oversedation and respiratory depression (American Society of Addiction Medicine, 2020). Delirium Patients experiencing delirium because of alcohol withdrawal often need to be admitted to intensive or critical care units to receive close nursing observation and supportive care such as regular vital sign monitoring and frequent reassessment. Intra- venous access should be established quickly to allow for rapid administration of fluids and medication. CIWA-Ar scores are not recommended to monitor withdrawal symptoms in patients with delirium, since they rely on patient-reported symptoms. Instead, Case study 2 John is a 48-year-old combat veteran who is admitted to the hos- pital after a fall. He is treated for a broken leg in the emergency department, but his wife notes that her husband is a heavy drinker and that his last drink was over 36 hours ago. She says that John has withdrawn from alcohol several times in the past and expe- rienced seizures and delirium on several occasions. John is very agitated and anxious, has a terrible headache and a tremor, and is sweating and vomiting. He also appears to be hallucinating—he is experiencing auditory and visual disturbances. The nurse adminis- ters a CIWA-Ar scale, and John scores a 23. Self-Assessment Quiz Question #4 Which of the following is NOT a risk factor for severe or compli- cated withdrawal that should be considered when developing a treatment plan for John? a. Age of 48 years. b. Long history of regular, heavy alcohol use. c. Numerous prior episodes of withdrawal. d. Prior history of alcohol withdrawal seizures or delirium.
a. Carbamazepine b. Phenobarbital c. Benzodiazepines d. Valproic acid
LONG-TERM MANAGEMENT OF ALCOHOL USE DISORDER
Treatment of alcohol use disorder should be a collaborative pro- cess between the patient and their provider. Including the patient’s family or support system can also be helpful if the patient gives their permission to include them. Treatment goals should be estab- lished prior to initiating therapy, and can range from reducing alco- hol use, to eliminating drinking in high-risk situations, to complete abstinence. Defining goals at the beginning of therapy is associ - ated with improved treatment outcomes (Reus et al., 2018). When possible, treatment for alcohol use disorder should be started concurrently with withdrawal treatment if cognitive status allows (American Society of Addiction Medicine, 2020). Patient
preference plays a significant role in choosing therapy. Some pa - tients prefer nonpharmacological therapy, while others prefer the use of medications. Offering all available options to patients can help ensure treatment plans are developed based on patient pref- erences and potentially improve adherence (Reus et al., 2018). Pharmacotherapy for patients with moderate to severe alcohol use disorder who have a goal of abstinence or reduced consump- tion of alcohol and want to initiate medication treatment should begin with naltrexone or acamprosate. These medications can also be considered in patients with mild alcohol use disorder if the patient prefers medication therapy (Reus et al., 2018).
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Book Code: RPUS3024
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