Alcohol withdrawal severity is decreased by symptom-orientated adjusted bolus therapy in the ICU.
OBJECTIVE
To examine the effect of bolus vs. continuous infusion adjustment on severity and duration of alcohol withdrawal syndrome (AWS), the medication requirements for AWS treatment, and the effect on ICU stay in surgical intensive care unit (ICU) patients.


METHODS
Prospective randomized, double-blind controlled trial in a surgical ICU.


METHODS
44 patients who developed AWS after admission to the ICU.


METHODS
Patients were randomized to either (a). a continuous infusion course of intravenous flunitrazepam (agitation), intravenous clonidine (sympathetic hyperactivity), and intravenous haloperidol (productive psychotic symptoms) if needed (infusion-titrated group), or (b). the same medication (flunitrazepam, clonidine, or haloperidol) bolus adjusted in response to the development of the signs and symptoms of AWS (bolus-titrated group).


RESULTS
The administration of "as-needed" medication was determined using a validated measure of the severity of AWS (Clinical Institute of Withdrawal Assessment). Although the severity of AWS did not differ between groups initially, it significantly worsened over time in the infusion-titrated group. This required a higher amount of flunitrazepam, clonidine, and haloperidol. ICU treatment was significantly shorter in the bolus-titrated group (median difference 6 days) due to a lower incidence of pneumonia (26% vs. 43%).


CONCLUSIONS
We conclude that symptom-orientated bolus-titrated therapy decreases the severity and duration of AWS and of medication requirements, with clinically relevant benefits such as fewer days of ventilation, lower incidence of pneumonia, and shorter ICU stay.
Spies
Claudia D
CD
Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Schumannstrasse 20/21, 10117, Berlin, Germany. claudia.spies@charite.de.
Otter
Hilke E
HE
Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Schumannstrasse 20/21, 10117, Berlin, Germany.
Hüske
Bernd
B
Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Schumannstrasse 20/21, 10117, Berlin, Germany.
Sinha
Pranav
P
Institute of Clinical Chemistry, Charité-Universitätsmedizin Berlin, Berlin, Germany.
Neumann
Tim
T
Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Schumannstrasse 20/21, 10117, Berlin, Germany.
Rettig
Jordan
J
School of Medicine, University of Connecticut, Conn., USA.
Lenzenhuber
Erika
E
Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin , Berlin, Germany.
Kox
Wolfgang J
WJ
Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Schumannstrasse 20/21, 10117, Berlin, Germany.
Sellers
Edward M
EM
Departments of Pharmacology, Medicine, and Psychiatry, University of Toronto, Toronto, Ont., Canada.
D000328:Adult; D000430:Alcohol Withdrawal Delirium / Q000145:classification / Q000188:drug therapy*; D014151:Anti-Anxiety Agents / Q000008:administration & dosage* / Q000009:adverse effects; D014150:Antipsychotic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D003000:Clonidine / Q000008:administration & dosage*; D003663:Decision Trees; D004311:Double-Blind Method; D005260:Female; D005445:Flunitrazepam / Q000008:administration & dosage* / Q000009:adverse effects; D006220:Haloperidol / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D007262:Infusions, Intravenous; D007362:Intensive Care Units; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D012720:Severity of Illness Index; D013565:Sympatholytics / Q000008:administration & dosage*
D014151:Anti-Anxiety Agents; D014150:Antipsychotic Agents; D013565:Sympatholytics; D005445:Flunitrazepam; D006220:Haloperidol; D003000:Clonidine