Alcohol withdrawal syndrome in ICU patients: Clinical features, management, and outcome predictors

Background Alcohol withdrawal syndrome (AWS) is a common condition in hospitalized patients, yet its epidemiology in the ICU remains poorly characterized. Methods Retrospective cohort of patients admitted to the Nantes University Hospital ICU between January 1, 2017, and December 31, 2019, and coded for AWS using ICD-10 criteria. The objective of the study was to identify factors associated with complicated hospital stay defined as ICU length of stay ≥7 days or hospital mortality. Results Among 5,641 patients admitted to the ICU during the study period, 246 (4.4%) were coded as having AWS. Among them, 42 had exclusion criteria and 204 were included in the study. The three main reasons for ICU admission were sepsis (29.9%), altered consciousness (29.4%), and seizures (24%). At ICU admission, median Cushman’s score was 6 [4–9] and median SOFA score was 3 [2–6]. Delirium tremens occurred in half the patients, seizures in one fifth and pneumonia in one third. Overall, 48% of patients developed complicated hospital stay, of whom 92.8% stayed in the ICU for ≥7 days, 36.7% received MV for ≥7 days, and 16.3% died during hospital stay. By multivariable analysis, two factors were associated with complicated hospital stay: a higher number of organ dysfunctions at ICU admission was associated with a higher risk of complicated hospital stay (OR, 1.18; 95CI, 1.05–1.32, P = 0.005), whereas ICU admission for seizures was associated with a lower risk of complicated hospital stay (OR, 0.14; 95%CI, 0.026–0.80; P = 0.026). Conclusions AWS in ICU patients chiefly affects young adults and is often associated with additional factors such as sepsis, trauma, or surgery. Half the patients experienced an extended ICU stay or death during the hospital stay. The likelihood of developing complicated hospital stay relied on the reason for ICU admission and the number of organ dysfunctions at ICU admission.

Quantitative Electroencephalographic Analysis of Delirium Tremens Development Following Alcohol-withdrawal Seizure

Seizures and delirium tremens (DTs) are recognized as severe alcohol-withdrawal symptoms. Prolonged admission and serious complications associated with alcohol-withdrawal are responsible for increased costs and use of medical and social resources. We compared differences in quantitative electroencephalography (EEG) in patients after alcohol-withdrawal seizures (AWS; n = 13), performed in the intensive care unit within 48 h of admission, and in age- and sex-matched healthy controls. We also investigated the prognostic value of quantitative EEG, for the development of alcohol DTs after AWS in a retrospective, case‒control study. The spectral power of each band frequency and the ratio of the theta to alpha band (TAR) in the electroencephalogram were analysed using iSyncBrain® (iMediSync, Inc., Korea). The beta frequency and the alpha frequency band power were significantly higher and lower, respectively, in patients than in age- and sex-matched healthy controls. In AWS patients with DTs, the relative beta3 power was lower, particularly in the left frontal area, and the TAR was significantly higher in the central channel than in those without DTs. Quantitative EEG showed neuronal excitability and decreased cognitive activities characteristic of AWS patients associated with alcohol withdrawal state and we demonstrated that quantitative EEG also might be a helpful tool for detecting patients at high risk of developing DTs during an alcohol-dependence period.

Modern Approach towards Clinical Evaluation and Treatment of Alcohol Psychoses

Based on the literature and our own data in article outlines current clinical picture of alcoholic psychosis (delirium tremens, hallusinosis, alcohol delusion psychoses, jealousy), and theirs modem treatment methods. To give separate recommendation on the therapy of the delirium tremens, hallusinosis, alcohol delusion psychoses, jealousy etc. These data are of great practical and theoretical significance.

On the importance of nonionic osmotically active substances of the blood for the pathogenesis of severe alcoholic delirium

The main non-ionic osmotically active substances in blood serum are glucose and urea. The aim of the study was to study the changes in the water-osmotic state caused by non-ionic (organic) substances in patients with delirium tremens (DT) and in a state of alcohol withdrawal, and to assess their influence on the blood leukocyte composition and the clinical manifestations of the disease. A total of 747 men were examined in a state of alcohol withdrawal; of these, 450 people had manifestations of severe DT (F10.43), 213 — “classic” DT (F10.4), 84 patients had signs of alcohol withdrawal with somatic and vegetative manifestations (F10.3). To quantitatively describe the composition of leukocytes, an index equal to the neutrophil to lymphocyte ratio (NL-R) was used. We were able to mathematically describe a previously unknown quantitative relationship between the osmolarity level due to non-ionic osmotically active substances in blood serum and the NL-R values. It is expressed by the following formula: G + U = 1 mmol/L (log2 NL-R + 9.5), where G — concentration of glucose in blood serum, mmol/l; U is the concentration of urea in the blood serum, mmol/l; NL-R — neutrophil-lymphocyte index, units; 1 mmol/l — coefficient providing the required dimension of the result; log2 — logarithm with base 2; 9.5 is a constant whose size depends on the selected system of units. It was found that regular changes in blood osmolarity in patients with alcohol withdrawal and DT, both at the stage of initiation of psychosis and during the progression of the disease and the formation of severe DT, occur mainly, and maybe completely, due to non-ionic osmotically active substances. Glucose and urea have their unique role in the formation of homeostasis disorders during the development of the disease in individuals with uncomplicated alcohol withdrawal, as well as DT of varying severity.

Comparative characteristics of ketamine and sodium oxybutyrate as adjuvant sedation in patients with alcoholic delirium

Annotation. Today, the number of benzodiazepine-resistant alcoholic deliriums is growing. It is actually to search for an optimal scheme of sedation with a combination of two sedatives. The aim of the study was to compare efficacy of standard sedation with added barbiturates and the schemes with using ketamine and sodium oxybutyrate. We tested 60 cases of delirium tremens which were randomized into three groups. In the control group we conducted the traditional sedation with added sodium thiopental. In the first research group we combined the infusion of ketamine with diazepam. In the second one we gave sodium oxybutyrate with diazepam. We evaluated the duration of delirium, hemodynamics parameters, serum cortisol and serotonin, laboratory indicators of kidneys and liver condition. We used such statistical methods as Mann-Whitney test, Wilcoxon T-criterion and Kruskal-Wallis H-criterion. The duration of delirium was significantly lower in research groups in comparison with the control one. There was no difference of the duration of delirium between research groups. It indicates a comparable effect of using either ketamine, or sodium oxybutyrate. All groups showed significant reduction of hemodynamics parameters in the process of the treatment, however we observed more cases of hypertension and tachycardia on the third day of the treatment in the research groups than in the control one. These data suggest an insufficient effect of the combination of diazepam with both ketamine and sodium oxybutyrate on the sympatho-adrenal system. Serum cortisol was significantly reduced in all the groups, there was no difference between control and research groups. Serotonin was equally increased in all the groups on the third day. The obtained results indicate that the effectiveness of the combination of benzodiazepines with both ketamine and sodium oxybutyrate is comparable to the standard sedation regimen and does not differ in the reaction of these biomarkers. The laboratory indicators of kidneys condition on the third day increased only in the research groups, which indicates more negative influence on kidneys by both ketamine and sodium oxybutyrate. The indicators of liver condition were significantly reduced only in the group of ketamine, there were no difference in the rest groups. The use of ketamine and sodium oxybutyrate as adjuvant sedation may reduce the duration of a delirium episode, but has insufficient effect on hemodynamics and may adversely affect renal function.