title: Outcomes of Patients with Alcohol Withdrawal Syndrome Treated with High-Dose Sedatives and Deferred Intubation.
abstract: BACKGROUND
  High doses of sedating drugs are often used to manage critically ill patients with alcohol withdrawal syndrome.
  
  
  OBJECTIVE
  To describe outcomes and risks for pneumonia and endotracheal intubation in patients with alcohol withdrawal syndrome treated with high-dose intravenous sedatives and deferred endotracheal intubation.
  
  
  METHODS
  Observational cohort study of consecutive patients treated in the intensive care unit (ICU) of a university-affiliated, community hospital for alcohol withdrawal syndrome, where patients were not routinely intubated to receive high-dose or continuously infused sedating medications.
  
  
  RESULTS
  We studied 188 patients hospitalized with alcohol withdrawal syndrome from 2008 through 2012 at one medical center. The mean age (SD) of the subjects was 50.8 ± 9.0 years and their mean ICU admission APACHE (Acute Physiology and Chronic Health Evaluation) II score was 6.2 ± 3.4. Thirty subjects (16%) developed pneumonia, and 38 (20.2%) required intubation. All of the 188 patients received lorazepam (median total dose, 42.5 mg), and 170 of 188 received midazolam, all but 2 by continuous intravenous infusion (median total dose, 527 mg; all administered in ICU); 19 received propofol (median total dose, 6,000 mg); and 19 received dexmedetomidine (median total dose, 1,075 mg). Intubated patients received substantially more benzodiazepine (median total dose, 761 mg of lorazepam equivalent vs. 229 mg for subjects in the nonintubated group; P < 0.0001). Endotracheal intubation was associated with pneumonia and higher acuity of illness (APACHE II score, >10). Intubated patients had a longer duration of hospital stay (median, 15 d vs. 6 d; P ≤ 0.0001). One patient did not survive hospitalization.
  
  
  CONCLUSIONS
  In this single-center, observational study, where endotracheal intubation was deferred until aspiration or cardiopulmonary decompensation, treatment of alcohol withdrawal syndrome with high-dose, continuously infused sedating medications was not associated with excess morbidity or mortality.
authors.affiliation: 1 Department of Internal Medicine, Texas A&M University, College Station, Texas.
authors.forename: Robert
authors.initials: R
authors.lastname: Stewart
authors.affiliation: 2 Hospital of Central Connecticut, New Britain, Connecticut.
authors.forename: Ricardo
authors.initials: R
authors.lastname: Perez
authors.affiliation: 2 Hospital of Central Connecticut, New Britain, Connecticut.
authors.forename: Bogdan
authors.initials: B
authors.lastname: Musial
authors.affiliation: 3 Department of Internal Medicine, University of Connecticut, Farmington, Connecticut; and.
authors.forename: Carrie
authors.initials: C
authors.lastname: Lukens
authors.affiliation: 4 Department of Internal Medicine, Yale University, New Haven, Connecticut.
authors.forename: Yaw Amoateng
authors.initials: YA
authors.lastname: Adjepong
authors.affiliation: 2 Hospital of Central Connecticut, New Britain, Connecticut.
authors.forename: Constantine A
authors.initials: CA
authors.lastname: Manthous
mesh_terms: D018806:APACHE; D000328:Adult; D020270:Alcohol Withdrawal Seizures / Q000209:etiology; D002492:Central Nervous System Depressants / Q000009:adverse effects; D015331:Cohort Studies; D016638:Critical Illness; D020927:Dexmedetomidine / Q000008:administration & dosage; D000431:Ethanol / Q000009:adverse effects; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage*; D007262:Infusions, Intravenous; D007362:Intensive Care Units; D007442:Intubation, Intratracheal / Q000379:methods* / Q000706:statistics & numerical data; D007902:Length of Stay / Q000706:statistics & numerical data; D016015:Logistic Models; D008140:Lorazepam / Q000008:administration & dosage; D008297:Male; D008874:Midazolam / Q000008:administration & dosage; D008875:Middle Aged; D011014:Pneumonia / Q000453:epidemiology; D015742:Propofol / Q000008:administration & dosage; D012121:Respiration, Artificial / Q000379:methods*; D012189:Retrospective Studies; D013375:Substance Withdrawal Syndrome / Q000209:etiology / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D002492:Central Nervous System Depressants; D006993:Hypnotics and Sedatives; D000431:Ethanol; D020927:Dexmedetomidine; D008140:Lorazepam; D008874:Midazolam; D015742:Propofol
keywords: alcohol withdrawal syndrome; delirium tremens; endotracheal intubation; sedation