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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Josh Farkas
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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 safer, more consistent and reliable. Thanks for another great podcast, I listen to them all.
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, RN, CCRN, CEN, CPEN
Clinical Nurse Manager
Intensive Care Unit
Central Vermont Medical Center
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