title: A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens.
abstract: OBJECTIVE
  Patients with severe alcohol withdrawal and delirium tremens are frequently resistant to standard doses of benzodiazepines. Case reports suggest that these patients have a high incidence of requiring intensive care and many require mechanical ventilation. However, few data exist on treatment strategies and outcomes for these subjects in the medical intensive care unit (ICU). Our goal was a) to describe the outcomes of patients admitted to the medical ICU solely for treatment of severe alcohol withdrawal and b) to determine whether a strategy of escalating doses of benzodiazepines in combination with phenobarbital would improve outcomes.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Inner-city municipal hospital.
  
  
  METHODS
  Subjects admitted to the medical ICU solely for the treatment of severe alcohol withdrawal.
  
  
  METHODS
  Institution of guidelines emphasizing escalating doses of diazepam in combination with phenobarbital.
  
  
  RESULTS
  Preguideline (n = 54) all subjects were treated with intermittent boluses of diazepam with an average total and maximal individual dose of 248 mg and 32 mg, respectively; 17% were treated with phenobarbital. Forty-seven percent required intubation due to inability to achieve adequate sedation and need for constant infusion of sedative-hypnotics. Intubated subjects had longer length of stay (5.6 vs. 3.4 days; p = .09) and higher incidence of nosocomial pneumonia (42 vs. 21% p = .08). Postguideline (n = 41) there were increases in maximum individual dose of diazepam (32 vs. 86 mg; p = .001), total amount of diazepam (248 vs. 562 mg; p = .001), and phenobarbital use (17 vs. 58%; p = .01). This was associated with a reduction in the need for mechanical ventilation (47 vs. 22%; p = .008), with trends toward reductions in ICU length of stay and nosocomial pneumonia.
  
  
  CONCLUSIONS
  Patients admitted to a medical ICU solely for treatment of severe alcohol withdrawal have a high incidence of requiring mechanical ventilation. Guidelines emphasizing escalating bolus doses of diazepam, and barbiturates if necessary, significantly reduced the need for mechanical ventilation and showed trends toward reductions in ICU length of stay and nosocomial infections.
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Oregon Health and Sciences University, Portland, OR, USA.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Gold
authors.forename: Binaya
authors.initials: B
authors.lastname: Rimal
authors.forename: Anna
authors.initials: A
authors.lastname: Nolan
authors.forename: Lewis S
authors.initials: LS
authors.lastname: Nelson
mesh_terms: D000328:Adult; D000430:Alcohol Withdrawal Delirium / Q000534:rehabilitation*; D015331:Cohort Studies; D003428:Cross Infection / Q000517:prevention & control; D003975:Diazepam / Q000008:administration & dosage*; D004305:Dose-Response Relationship, Drug; D004359:Drug Therapy, Combination; D005260:Female; D006773:Hospitals, Municipal; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage*; D007362:Intensive Care Units; D007442:Intubation, Intratracheal; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010634:Phenobarbital / Q000008:administration & dosage*; D018410:Pneumonia, Bacterial / Q000517:prevention & control; D017410:Practice Guidelines as Topic; D011595:Psychomotor Agitation / Q000517:prevention & control; D012121:Respiration, Artificial / Q000706:statistics & numerical data; D012189:Retrospective Studies; D014600:Utilization Review
chemical_list: D006993:Hypnotics and Sedatives; D003975:Diazepam; D010634:Phenobarbital