Below is a card from one of the first patients I treated for alcohol withdrawal. He lingered in the hospital for days on various benzodiazepine regimens (including a lorazepam infusion), and eventually limped home on an oral chlordiazepoxide taper. He wrote me a thank-you card days after leaving the hospital, but as you can see he still had a tremor:
We've come a long ways since then. Currently, phenobarbital monotherapy is replacing benzodiazepines as the front-line therapy for alcohol withdrawal at many institutions. Phenobarbital offers the ability to provide faster and more definitive therapy for alcohol withdrawal, while avoiding extended ICU stays for repeated doses of benzodiazepines. Although benzodiazpines (particularly IV diazepam) remain adequate for milder cases, this chapter focuses on phenobarbital as a more powerful and versatile approach.
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The IBCC chapter is located here.
- The podcast & comments are below (Because the podcast is a true monster it's not ready yet. It will be out soon. If you're having an acute withdrawal reaction due to the lack of a podcast, you can watch the below video from a talk about phenobarbital I gave a couple years ago).
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Enlightening discussion. Currently my hospital’s protocol involves CIWA scoring Q4hrs and Q1hr after administering a dose of lorazepam. Which is the current drug of choice. According to the protocol you could potentially be redosing the patient with lorazepam every single hour. As an RN who is the person scoring and medicating the patient I can say first hand it is a pain… it is hard to achieve consistent symptomatic relief for the patients and you often find yourself playing catch-up. It’s like riding a roller coaster. Would love to see phenobarbital implemented as the standard as you have described. Seems… Read more »
Hannah – We equally run into the problem of CIWA. Remember, to adequately use CIWA, you must have a patient able to self-report. CIWA becomes less reliable as delirium or sedation increases. We have ran into numerous problems with the subjective reporting of CIWA. We are looking at adopting MINDS (Minnesota Detoxification Scale). It does not require the withdrawing patient to self report. We are preparing it to present to Josh’s colleague, Dr. Gill Allen, at our Critical Care Committee in September. MINDS + RASS will provide a great assessment of our withdrawing patient. https://www.aacn.org/docs/cemedia/a1827042.pdf https://content.wellspan.org/CPOE/Service%20Line%20Folders/Medicine/MINDS%20Alcohol%20withdrawal.pdf https://www.anwhospitalist.com/wp-content/uploads/2019/01/MINDS-poster-MN-ACP-2018.pdf. Scott Bagg, BSN,… Read more »
Do you have any thoughts on the benzo-sparing protocol by Maldonado? My hospital is beginning to adopt it, but I have some concerns. https://www.ncbi.nlm.nih.gov/pubmed/28601135
I had a chance to try this regimen, seemed to have worked well. Otherwise healthy patient with clear time of last drink, now extremely agitated but still oriented / no delirium and cooperative. 100mg of diazepam in the first hour had virtually no effect on him. Within 1 hour of slowly administering 120mg doses of phenobarb q15 mins (no loading dose because of the previous benzos on board) he was sleeping comfortably but still easily awakened, no respiratory depression. He didn’t even get a full 10 mg/kg loading dose likely due to the benzos used up front. This morning he… Read more »
We started using phenobarbital in the reservation hospital to prevent and treat alcohol withdrawal because of your website, about a year ago. We have had no treatment failures or cases of oversedation since, as we did in the past with benzodiazepines. The patients themselves, always state that they would prefer phenobarbital in the future (the rate of alcoholism is about 85% on this reservation so, sadly, many return after a short period of time ). In addition, our dedicated but overworked nurses have been pleased to be rid of the hated CIWA protocol. In short, like all good instructors, you… Read more »