title: Management of Acute Alcohol Withdrawal Syndrome in Critically Ill Patients.
abstract: Approximately 16-31% of patients in the intensive care unit (ICU) have an alcohol use disorder and are at risk for developing alcohol withdrawal syndrome (AWS). Patients admitted to the ICU with AWS have an increased hospital and ICU length of stay, longer duration of mechanical ventilation, higher costs, and increased mortality compared with those admitted without an alcohol-related disorder. Despite the high prevalence of AWS among ICU patients, no guidelines for the recognition or management of AWS or delirium tremens in the critically ill currently exist, leading to tremendous variability in clinical practice. Goals of care should include immediate management of dehydration, nutritional deficits, and electrolyte derangements; relief of withdrawal symptoms; prevention of progression of symptoms; and treatment of comorbid illnesses. Symptom-triggered treatment of AWS with γ-aminobutyric acid receptor agonists is the cornerstone of therapy. Benzodiazepines (BZDs) are most studied and are often the preferred first-line agents due to their efficacy and safety profile. However, controversy still exists as to who should receive treatment, how to administer BZDs, and which BZD to use. Although most patients with AWS respond to usual doses of BZDs, ICU clinicians are challenged with managing BZD-resistant patients. Recent literature has shown that using an early multimodal approach to managing BZD-resistant patients appears beneficial in rapidly improving symptoms. This review highlights the results of recent promising studies published between 2011 and 2015 evaluating adjunctive therapies for BZD-resistant alcohol withdrawal such as antiepileptics, baclofen, dexmedetomidine, ethanol, ketamine, phenobarbital, propofol, and ketamine. We provide guidance on the places in therapy for select agents for management of critically ill patients in the presence of AWS.
authors.affiliation: Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey.|Critical Care, Robert Wood Johnson University Hospital, New Brunswick, New Jersey.
authors.forename: Deepali
authors.initials: D
authors.lastname: Dixit
authors.affiliation: University of Vermont Medical Center, Burlington, Vermont.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Endicott
authors.affiliation: Mt. Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Lisa
authors.initials: L
authors.lastname: Burry
authors.affiliation: New York-Presbyterian Weill Cornell Medical Center, New York, New York.
authors.forename: Liz
authors.initials: L
authors.lastname: Ramos
authors.affiliation: University of Maryland Medical Center, Baltimore, Maryland.
authors.forename: Siu Yan Amy
authors.initials: SY
authors.lastname: Yeung
authors.affiliation: University of Maryland School of Pharmacy, Baltimore, Maryland.
authors.forename: Sandeep
authors.initials: S
authors.lastname: Devabhakthuni
authors.affiliation: Yale-New Haven Hospital, New Haven, Connecticut.
authors.forename: Claire
authors.initials: C
authors.lastname: Chan
authors.affiliation: Division of Psychiatry, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.
authors.forename: Anthony
authors.initials: A
authors.lastname: Tobia
authors.affiliation: Harrison School of Pharmacy, Auburn University, Auburn, Alabama.|Department of Internal Medicine, College of Community Health Sciences, University of Alabama, Tuscaloosa, Alabama.
authors.forename: Marilyn N
authors.initials: MN
authors.lastname: Bulloch
mesh_terms: D001418:Baclofen / Q000627:therapeutic use; D001569:Benzodiazepines / Q000627:therapeutic use; D016638:Critical Illness; D020927:Dexmedetomidine / Q000627:therapeutic use; D000431:Ethanol / Q000009:adverse effects*; D006801:Humans; D007902:Length of Stay; D010634:Phenobarbital / Q000627:therapeutic use; D013375:Substance Withdrawal Syndrome / Q000188:drug therapy*
chemical_list: D001569:Benzodiazepines; D000431:Ethanol; D020927:Dexmedetomidine; D001418:Baclofen; D010634:Phenobarbital
keywords: alcohol; alcohol withdrawal syndrome; benzodiazepines; critical care; delirium tremens; intensive care; sedatives; withdrawal