I CAME ACROSS YOUR BLOG AND FOUND MYSELF PRETTY DISMAYED. IT IS MY UNDERSTANDING THAT WE SHOOULD SCREEN PATIENTS FOR ALCOHOL ABUSE, PUT THEM ON A WITHDRAWL PROTOCOL TO PREVENT DT'S. REFER THEM TO ADDICTION SPECIALISTS. HAVE YOU NOT HEARD OF CIWA OR THE CAGE QUESTIONAIRE?
TKientzRN@aol.com

Thank you for your comment.
I am very familiar with a variety of alcohol withdrawal and assessment scales. Indeed, I helped to introduce an alcohol withdrawal protocol to our ICU. This is a great tool that works in MOST cases. There are few patients, though, who simply do not respond to even huge doses of sedatives. In the past we used to put those patients on a ventilator so we could sedate them. The introduction of a newer drug – Precedex, often allows us to avoid intubation in these “dramatic” cases.
The point of the discussion here, though, is should we be giving alcohol (to some patients and only by a physician’s order) to the patients in the hospital.
In reality, we used to do that. We also saw less alcohol withdrawal and less complications arising from the withdrawal. There are multiple reasons why we are not giving alcohol in the hospital anymore.
With all the scales and tools to monitor and treat patients for this life threatening condition, I still see patients going thru severe DTs all too often…

Wow - quick response. Thank you. I m a graduate student in Nursing with too many years of critical care nursing under my belt.I have become interested in how we care for alcoholics in the acute care setting. I now work on a relatively tame Tele Unit, and not long ago we ended up with a patient in leather restraints, because, I feel, our docs didn't use enough ativan. This guy should have been transferred to the ICU and put on a drip of some sort! I have seen withdrawl patients placed on propofol, but they do end up intubated. But it simply was not seen as a medical emergency. We used tons of resources, including round the clock sitters, and to what end? Did anyone refer him to the addiction team? Nope. We were so glad to get him out of our unit no thought was given to his final outcome. I just think this is unethical.

In terms of giving alcohol to patients to prevent withdrawl - I don't favor this idea because if they are truly alcohol dependent, we are simply giving them more poisen. That said, it probably comes down to a risk/benifit ratio..the risk of continued alcohol use vs the danger of withdrawl.

Interesting discussion. You may have seen a group of articles in a supplement to The Journal Of Trauma - Injury, Infection, and Critical Care, 2005;59. I found the read fascinating, highlighting what we have accomplished in terms of trauma care...and where we should look for what is called further "Upstream Thinking".

Have a safe and sober day!

Alcoholism is a horrible problem. From medical standpoint, excessive amounts of alcohol affects most of the major systems in the body including heart, liver, brain etc.

Alcohol abuse has major social implications as well. Personal lives are being ruined, families are being destroyed.

Yet, the decision to abstain from alcohol could only be made on an individual level. How many times have I asked a case manager/social worker to look into the alcohol rehab options for a patient with alcoholism. All that the case manager could do is to give the patient a bunch of brochures with the address of the outpatient rehab programs.

Unless the patient himself is willing to go through rehab those efforts are usually fruitless (Court ordered rehab may be an exception)

If the patient is not willing to quit drinking, putting this patient through alcohol withdrawal might not be the best solution either. Spending days (sometimes weeks) in the Intensive Care Unit just to go home and resume drinking is what usually happens.

Many if not most patients going through DTs do not have medical insurance and cannot afford their hospital bills. That puts us, taxpayers on the hook for those “unwanted” rehab visits to the hospital.

As a gastroenterologist/ hepatologist with an interest in alcohol toxicity and alcoholic liver disease I can say GPH is completely on target. Benzodiazepines work most of the time but not all the time. The former ICU nurses" leather restraint" vignette is stereotypical of the general nursing complaint. From his/her point of view there has to be "a drip of some sort" that you can give enough of fast enough to make the patient and most particularly the nurse more comfortable. Like all receptors benzodiazepine receptors eventually saturate and probably are heavily down regulated in severe alcoholics. So to make the point, if the patient has one lonely receptor left and you bind it with lorazepam, then you can give all the drips of lorazepam you want and they will still be thrashing in restraints. Not only that, they may not clear the drug for days. There they sit in your ICU for days after the DT's are gone with iatrogenic drug induced delerium. Most ICU staff will be unable to make the distinction between drug toxicity and DT's and may assume they need ever more...

I am afraid benzo drips are not the Holy Grail of withdrawal management. They are, to be sure, better than nothing but like ethanol, they are just another drug with the all the peculiar risks and benefits that drugs will always have.

 
Thank you very much for your comments.
Managing a severe alcohol withdrawal is not an easy task. From my clinical experience – even escalating doses of benzodiazepines are often not enough to “contain” patients in severe DTs.
And as you mentioned, 3 – 5 days into the withdrawal, you are no longer sure if you are dealing with alcohol withdrawal or iatrogenic delirium.
Our clinical practice will likely to evolve in the years to come. For right now, though, the patient in DTs remains a clinical challenge.

I couldnt agree more. With alcoholism on the rise, serving a few drinks to keep patients at bay is certainly a better option than ending up trached because you had to be intubated and now its day 14 and you have VAP. This would without a doubt save billions.

The number of ETOH detox patients in our icu is increasing. More and more, they are being intubated and sedated on propofol. The ativan gtt is no longer effective and so much of it is required, the pt can no longer breath. We have been discussing this topic a lot lately since it is often the same patients that continually come back through the revolving door. We are tired of being beaten up by them we are tired of them wasting thousands of dollars when they have no interest in quitting anyway. Then there is the surgical patient who starts to detox on day two of his THA recovery. Now he's in a bed thrashing around and popping his new hip out of its socket and finally having to be intubated. We see this scenario over and over. Unless it's a pt who is there specifically to detox, then it seems like a no brainer to me that we should let them do what they're going to do when they get home anyway. We allow our 400LB patients to eat Big Macs and fries brought in to them by their families....what's the difference.

I am an ICU nurse and Clinical Leader that was recently hit (not the first time) and kicked by an ETOH-er. He had received 250 mg of IV Lorazepam in 56 hours and it was obviously not working. Changing to dexmetomidine was truly a life saver. But why are we doing this?
I am all for helping people who wish to help themselves, or even just say that they wish to. But if someone comes in with a dx that does not make them NPO, why can't we give them alcohol?
Some people have no interest in detoxing (and these are the ones that I am talking about). I understand that we cannot condone alcohol use, but when does the safety of the staff become more important. Two + weeks in the ICU for "accidental" withdrawal when all you wanted was your bum knee fixed is not ok. What are the costs? Emotional for the family to see their loved one in 4 points. Physical for the staff (and family). Financial for the patient. Isn't there a way to change this?
I have been looking on Pubmed and Medline and not really finding any sort of protocol for actual oral intake of alcohol. Does anyone know of one?
Any comments or questions are appreciated. Thanks for this interesting discussion that I am only now coming across.