Risk for delirium tremens in patients with alcohol withdrawal syndrome1

Objective: To report a case of alcohol withdrawal and delirium tremens successfully treated with adjunctive dexmedetomidine. Case Summary: A 30–year-old man with a history of alcohol abuse was admitted to the general medical unit because of altered mental status and agitation. He was initially treated for alcohol withdrawal with benzodiazepines; his condition then deteriorated and he was transferred to the intensive care unit. Because of the patient's poor response to benzodiazepines (oxazepam and lorazepam, with midazolam the last one used), intravenous dexmedetomidine was started at an initial dose of 0.2 µg/kg/h and titrated to 0.7 µg/kg/h to the patient's comfort. Midazolam was subsequently tapered to discontinuation due to excessive sedation. In the intensive care unit, the patient's symptoms remained controlled with use of dexmedetomidine alone. He remained in the intensive care unit for 40 hours; dexmedetomidine was then tapered to discontinuation and the patient was transferred back to the general medical unit on oral oxazepam and thiamine, which had been started in the emergency department. He was discharged after 5 days. Discussion: A review of the PubMed database (1989-2007} failed to identify any other instances of dexmedetomidine having been used as the principal agent to treat alcohol withdrawal. The use of sedative to treat delirium tremens Is well documented, with benzodiazepines being the agents of choice. The clinical utility of benzodiazepines is limited by their stimulation of the γ-aminobutyric acid receptors, an effect not shared by dexmedetomidine, a central α2-receptor agonist that induces a state of cooperative sedation and does not suppress respiratory drive. Conclusions: In patients with delirium tremens, dexmedetomidine should be considered as an option for primary treatment. This case illustrates the need for further studies to investigate other potential uses for dexmedetomidine.

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Prevention of Delirium Tremens and Management of Alcohol Withdrawal Syndrome

Surviving Prescribing ◽

10.1017/9781108776936.008 ◽

2020 ◽

pp. 39-42

Author(s):

Robert Shulman

Keyword(s):

Alcohol Withdrawal ◽

Withdrawal Syndrome ◽

Delirium Tremens ◽

Alcohol Withdrawal Syndrome

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Alcohol withdrawal and treatment

Therapeutische Umschau ◽

10.1024/0040-5930.57.4.257 ◽

2000 ◽

Vol 57 (4) ◽

pp. 257-260 ◽

Cited By ~ 8

Author(s):

Croissant ◽

Mann

Keyword(s):

Alcohol Withdrawal ◽

Delirium Tremens ◽

Medikamentöse Behandlung

Wenn Alkoholabhängige die Alkoholzufuhr abrupt vermindern oder unterbrechen, kommt es in der Regel zur Ausbildung eines Alkoholentzugssyndroms. In den meisten Fällen entwickelt sich ein vegetatives Syndrom mit Störungen des Magen-Darm-Traktes, des Kreislaufes, der Atmung und des ZNS. In der Regel klingen die Hauptsymptome des Entzugssyndroms nach vier bis sieben Tagen ab, längere Verläufe sind selten. Eine medikamentöse Behandlung ist bei rund einem Drittel der Patienten erforderlich. Hierfür wurde eine Fülle von Pharmaka vorgeschlagen. In den ersten Stunden nach dem Alkoholentzug ist die Sensibilität der Noradrenalinrezeptoren erniedrigt, steigt dann aber erheblich an. Die Zahl der NMDA-Rezeptoren nimmt durch chronische Intoxikation mit Ethanol zu. Der Standard der Therapie basiert vorwiegend auf der oralen Monotherapie mit Clomethiazol und alternativ mit Benzodiazepinen. Die Höhe der Dosis orientiert sich an der Ausprägung der Symptomatik. Bei schwerer Entzugssymptomatik kann die Behandlung auf einer Intensivstation mit Infusionstherapie notwendig werden, z.B. im Rahmen eines Delirium tremens, welches einen lebensbedrohlichen Zustand darstellt. Hier haben sich neben Clomethiazol auch Benzodiazepine bewährt.

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P0227 RISK FACTORS FOR DELIRIUM TREMENS IN PATIENTS WITH ALCOHOL WITHDRAWAL SYNDROME IN A HOSPITAL SETTING

European Journal of Internal Medicine ◽

10.1016/s0953-6205(09)60247-8 ◽

2009 ◽

Vol 20 ◽

pp. S81

Author(s):

Rafael Monte ◽

Ramón Rabuñal ◽

Milagros Peña ◽

Hugo López ◽

Ana Pazos ◽

...

Keyword(s):

Risk Factors ◽

Alcohol Withdrawal ◽

Withdrawal Syndrome ◽

Delirium Tremens ◽

Hospital Setting ◽

Alcohol Withdrawal Syndrome

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Alcohol intoxication

10.1093/med/9780199568741.003.0083 ◽

2018 ◽

Author(s):

Satish Keshav ◽

Palak Trivedi

Keyword(s):

Alcohol Abuse ◽

Alcohol Withdrawal ◽

Physical Dependence ◽

Alcohol Intoxication ◽

Delirium Tremens ◽

Alcohol Withdrawal Syndrome ◽

Altered Mental Status ◽

Severe Form ◽

Alcoholic Beverages ◽

Broad Term

Alcohol intoxication occurs when the quantity of alcohol (ethanol) consumed exceeds one’s tolerance for the substance, with consequent impairment of the individual’s mental and physical functional status. Alcohol abuse is a broad term for general ill health (mental, social, and/or physical) resulting from the repetitive, compulsive, and uncontrolled consumption of alcoholic beverages. Manifestations of alcohol abuse include a failure to fulfil one’s responsibilities, resulting in loss of employment, personal relationships, or finances. Alcohol dependence is a condition which arises as a result of alcohol abuse and occurs when an individual continually uses alcohol despite significant areas of dysfunction, with evidence of physical dependence.Alcohol withdrawal syndrome is the set of symptoms and physical signs observed when an individual reduces or abruptly stops alcohol consumption after prolonged periods of excessive intake; it is largely due to the development of a ‘hyperexcitable’ central nervous system. Delirium tremens is the most severe form of alcohol withdrawal; it manifests as altered mental status, hallucinations, and sympathetic overdrive, which may progress to cardiovascular collapse if left untreated.

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Alcohol Withdrawal Syndrome in Critically Ill Patients: Identification, Assessment, and Management

Critical Care Nurse ◽

10.4037/ccn2016420 ◽

2016 ◽

Vol 36 (1) ◽

pp. 28-38 ◽

Cited By ~ 10

Author(s):

Lynsey J. Sutton ◽

Annemarie Jutel

Keyword(s):

At Risk ◽

Alcohol Consumption ◽

Critically Ill ◽

Critically Ill Patients ◽

Alcohol Withdrawal ◽

Withdrawal Syndrome ◽

Delirium Tremens ◽

Alcohol Withdrawal Syndrome ◽

Rapid Identification ◽

Severe Withdrawal

Management of alcohol withdrawal in critically ill patients is a challenge. The alcohol consumption histories of intensive care patients are often incomplete, limiting identification of patients with alcohol use disorders. Abrupt cessation of alcohol places these patients at risk for alcohol withdrawal syndrome. Typically benzodiazepines are used as first-line therapy to manage alcohol withdrawal. However, if patients progress to more severe withdrawal or delirium tremens, extra adjunctive medications in addition to benzodiazepines may be required. Sedation and mechanical ventilation may also be necessary. Withdrawal assessment scales such as the Clinical Institute of Withdrawal Assessment are of limited use in these patients. Instead, general sedation-agitation scales and delirium detection tools have been used. The important facets of care are the rapid identification of at-risk patients through histories of alcohol consumption, management with combination therapies, and ongoing diligent assessment and evaluation. (Critical Care Nurse. 2016;36[1]:28–39)

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Clinical predictors for delirium tremens in patients with alcohol withdrawal seizures

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2015.02.030 ◽

2015 ◽

Vol 33 (5) ◽

pp. 701-704 ◽

Cited By ~ 13

Author(s):

Dong Wook Kim ◽

Hyun Kyung Kim ◽

Eun-Kee Bae ◽

So-Hee Park ◽

Kwang Ki Kim

Keyword(s):

Alcohol Withdrawal ◽

Delirium Tremens ◽

Clinical Predictors

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Thrombocytopenia in Early Alcohol Withdrawal is Associated with Development of Delirium Tremens or Seizures

Alcohol and Alcoholism ◽

10.1093/alcalc/agp012 ◽

2009 ◽

Vol 44 (4) ◽

pp. 382-386 ◽

Cited By ~ 21

Author(s):

U. Berggren ◽

C. Fahlke ◽

K. J. Berglund ◽

K. Blennow ◽

H. Zetterberg ◽

...

Keyword(s):

Alcohol Withdrawal ◽

Delirium Tremens

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Repetitive Myocardial Infarctions Secondary to Delirium Tremens

Case Reports in Critical Care ◽

10.1155/2014/638493 ◽

2014 ◽

Vol 2014 ◽

pp. 1-3

Author(s):

David Schwartzberg ◽

Adam Shiroff

Keyword(s):

Myocardial Infarction ◽

Myocardial Ischemia ◽

Alcohol Withdrawal ◽

Delirium Tremens ◽

Oxygen Demand ◽

Myocardial Infarctions ◽

Myocardial Oxygen Demand ◽

Significant Morbidity ◽

St Segment ◽

Patients Experience

Delirium tremens develops in a minority of patients undergoing acute alcohol withdrawal; however, that minority is vulnerable to significant morbidity and mortality. Historically, benzodiazepines are given intravenously to control withdrawal symptoms, although occasionally a more substantial medication is needed to prevent the devastating effects of delirium tremens, that is, propofol. We report a trauma patient who required propofol sedation for delirium tremens that was refractory to benzodiazepine treatment. Extubed prematurely, he suffered a non-ST segment myocardial infarction followed by an ST segment myocardial infarction requiring multiple interventions by cardiology. We hypothesize that his myocardial ischemia was secondary to an increased myocardial oxygen demand that occurred during his stress-induced catecholamine surge during the time he was undertreated for delirium tremens. This advocates for the use of propofol for refractory benzodiazepine treatment of delirium tremens and adds to the literature on the instability patients experience during withdrawal.

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