Symptom-driven lorazepam protocol for treatment of severe alcohol withdrawal delirium in the intensive care unit.
OBJECTIVE
To compare outcomes of treating alcohol withdrawal delirium (AWD) with a symptom-driven benzodiazepine protocol versus nonprotocol benzodiazepine infusions in the intensive care unit (ICU).


METHODS
Retrospective observational study of a quality improvement project.


METHODS
Medical intensive care unit at a Veterans Affairs medical center.


METHODS
Thirty-six patients who had 40 ICU admissions for AWD between January 1, 1994, and May 31, 2003. Sixteen episodes (15 patients [historical controls]) occurred before implementation of the symptom-driven protocol in 1998, and 24 episodes (21 patients) occurred after implementation.


RESULTS
Outcomes evaluated were time to reach symptom control, total dose of benzodiazepine, amount of time receiving continuous benzodiazepine infusion, length of ICU and hospital stay, polypharmacy (use of multiple benzodiazepines), and complications of treatment. The historical control group was treated according to physician preference, which consisted of continuous-infusion midazolam without a protocol. The symptom-driven protocol used lorazepam administered initially as intermittent intravenous doses, progressing to a continuous intravenous infusion according to a locally developed symptom scale. The mean +/- SD values for the outcomes in the historical control group versus the protocol group were as follows: time to control symptoms 19.4 +/- 9.7 versus 7.7 +/- 4.9 hours (p=0.002), cumulative benzodiazepine dose in lorazepam equivalents 1677 +/- 937 versus 1044 +/- 534 mg (p=0.014), time receiving benzodiazepine continuous infusion 122.1 +/- 64.4 versus 52.0 +/- 35.1 hours (p=0.001), length of stay in the ICU 7.7 +/- 6.3 versus 5.6 +/- 1.7 days (p=0.21), and length of hospital stay 15.3 +/- 8.9 versus 11.2 +/- 3.4 days (p=0.43).


CONCLUSIONS
Use of a symptom-driven protocol was associated with significantly decreased time to symptom control, amount of sedative required, and time spent receiving benzodiazepine infusion compared with historical controls. The use of the protocol is effective but requires close monitoring to ensure protocol compliance and to avoid potential propylene glycol toxicity.
DeCarolis
Douglas D
DD
Department of Pharmacy, Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota 55417, USA.
Rice
Kathryn L
KL
Ho
Libin
L
Willenbring
Mark L
ML
Cassaro
Susan
S
D000430:Alcohol Withdrawal Delirium / Q000188:drug therapy*; D014151:Anti-Anxiety Agents / Q000008:administration & dosage / Q000493:pharmacokinetics / Q000627:therapeutic use; D001569:Benzodiazepines / Q000008:administration & dosage / Q000493:pharmacokinetics / Q000627:therapeutic use; D002985:Clinical Protocols / Q000592:standards; D004334:Drug Administration Schedule; D005260:Female; D006207:Half-Life; D006760:Hospitalization / Q000706:statistics & numerical data; D006787:Hospitals, Veterans; D006801:Humans; D007262:Infusions, Intravenous; D007275:Injections, Intravenous; D007362:Intensive Care Units; D007902:Length of Stay; D008140:Lorazepam / Q000008:administration & dosage / Q000493:pharmacokinetics / Q000627:therapeutic use*; D008297:Male; D008874:Midazolam / Q000008:administration & dosage / Q000493:pharmacokinetics / Q000627:therapeutic use; D008875:Middle Aged; D011412:Propanolamines / Q000008:administration & dosage / Q000493:pharmacokinetics / Q000627:therapeutic use; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D016896:Treatment Outcome
D014151:Anti-Anxiety Agents; D011412:Propanolamines; D001569:Benzodiazepines; C036604:esmolol; D008140:Lorazepam; D008874:Midazolam