title: Approach to the Complicated Alcohol Withdrawal Patient.
abstract: Alcohol withdrawal syndromes are common causes for admission to the intensive care unit. As many as one-fifth of the admitted patients have an alcohol-associated disorder. Identifying the benefit of the γ-aminobutyric acid (GABA) agonists has shifted toward methods to improve benzodiazepine (BZD) utilization. Literature validating this treatment approach in severe withdrawal, especially in the critical care setting, is limited, and extrapolation to this population may be dangerous. Multiple therapies have been suggested or utilized in the literature including continuous infusion of GABA agonists, ethanol, dexmedetomidine, antiepileptics, and antipsychotics, introducing a significant amount of variability into clinical practice. This variability in treatment approaches highlights the lack of uniformity and recommendations available for the treatment of severe refractory patients. In patients progressing to severe withdrawal, it may be warranted to escalate care with adjunctive or more aggressive therapies. Although multiple practices are commonly used, the evidence supporting their use after failing symptom-triggered or aggressive therapy with BZDs is virtually nonexistent. These patients commonly receive a multimodal approach, which varies substantially between providers and institutions. Further literature should be directed at the approach most likely to provide benefit when standard of care has failed.
authors.affiliation: University of Florida Health Jacksonville, Jacksonville, FL, USA jason.ferreira@jax.ufl.edu.
authors.forename: Jason A
authors.initials: JA
authors.lastname: Ferreira
authors.affiliation: University of Florida College of Pharmacy, Jacksonville, FL, USA.
authors.forename: Patrick M
authors.initials: PM
authors.lastname: Wieruszewski
authors.affiliation: University of Florida College of Pharmacy, Jacksonville, FL, USA.
authors.forename: David W
authors.initials: DW
authors.lastname: Cunningham
authors.affiliation: University of Florida College of Pharmacy, Jacksonville, FL, USA.
authors.forename: Kimberly E
authors.initials: KE
authors.lastname: Davidson
authors.affiliation: University of Florida College of Pharmacy, Jacksonville, FL, USA.
authors.forename: Stephanie F
authors.initials: SF
authors.lastname: Weisberg
mesh_terms: D001569:Benzodiazepines / Q000627:therapeutic use*; D003422:Critical Care / Q000379:methods*; D020927:Dexmedetomidine / Q000627:therapeutic use*; D004359:Drug Therapy, Combination; D000431:Ethanol / Q000009:adverse effects*; D058785:GABA-A Receptor Agonists / Q000627:therapeutic use*; D006801:Humans; D006993:Hypnotics and Sedatives; D007262:Infusions, Intravenous; D007362:Intensive Care Units; D017410:Practice Guidelines as Topic; D012720:Severity of Illness Index; D013375:Substance Withdrawal Syndrome / Q000188:drug therapy* / Q000503:physiopathology
chemical_list: D058785:GABA-A Receptor Agonists; D006993:Hypnotics and Sedatives; D001569:Benzodiazepines; D000431:Ethanol; D020927:Dexmedetomidine
keywords: alcohol; alcohol withdrawal; critical care; intensive care