title: A Symptom-Triggered Benzodiazepine Protocol Utilizing SAS and CIWA-Ar Scoring for the Treatment of Alcohol Withdrawal Syndrome in the Critically Ill.
abstract: BACKGROUND
  There are limited data on the efficacy of symptom-triggered therapy for alcohol withdrawal syndrome (AWS) in the intensive care unit (ICU).
  
  
  OBJECTIVE
  To evaluate the safety and efficacy of a symptom-triggered benzodiazepine protocol utilizing Riker Sedation Agitation Scale (SAS) scoring for the treatment of AWS in the ICU.
  
  
  METHODS
  We performed a before-and-after study in a medical ICU. A protocol incorporating SAS scoring and symptom-triggered benzodiazepine dosing was implemented in place of a protocol that utilized the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale and fixed benzodiazepine dosing.
  
  
  RESULTS
  We enrolled 167 patients (135 in the preintervention and 32 in the postintervention group). The median duration of AWS was shorter in the postintervention (5, interquartile range [IQR] = 4-8 days) than in the preintervention group (8, IQR = 5-12 days; P < 0.01). Need for mechanical ventilation (31% vs 57%, P = 0.01), median ICU length of stay (LOS; 4, IQR = 2-7, vs 7, IQR = 4-11 days, P = 0.02), and hospital LOS (9, IQR = 6-13, vs 13, IQR = 9-18 days; P = 0.01) were less in the postintervention group. There was a reduction in mean total benzodiazepine exposure (74 ± 159 vs 450 ± 701 mg lorazepam; P < 0.01) in the postintervention group.
  
  
  CONCLUSIONS
  A symptom-triggered benzodiazepine protocol utilizing SAS in critically ill patients is associated with a reduction in the duration of AWS treatment, benzodiazepine exposure, need for mechanical ventilation, and ICU and hospital LOS compared with a CIWA-Ar-based protocol using fixed benzodiazepine dosing.
authors.affiliation: 1 Lahey Hospital and Medical Center, Burlington, MA, USA.|2 Tufts University School of Medicine, Boston, MA, USA.
authors.forename: Soumitra
authors.initials: S
authors.lastname: Sen
authors.affiliation: 1 Lahey Hospital and Medical Center, Burlington, MA, USA.|3 MCPHS University, Boston, MA, USA.
authors.forename: Philip
authors.initials: P
authors.lastname: Grgurich
authors.affiliation: 3 MCPHS University, Boston, MA, USA.|4 Singapore General Hospital, Singapore, Singapore.
authors.forename: Amanda
authors.initials: A
authors.lastname: Tulolo
authors.affiliation: 5 Tufts University, Medford, MA, USA.
authors.forename: Andrew
authors.initials: A
authors.lastname: Smith-Freedman
authors.affiliation: 1 Lahey Hospital and Medical Center, Burlington, MA, USA.
authors.forename: Yuxiu
authors.initials: Y
authors.lastname: Lei
authors.affiliation: 1 Lahey Hospital and Medical Center, Burlington, MA, USA.|2 Tufts University School of Medicine, Boston, MA, USA.
authors.forename: Anthony
authors.initials: A
authors.lastname: Gray
authors.affiliation: 1 Lahey Hospital and Medical Center, Burlington, MA, USA.|2 Tufts University School of Medicine, Boston, MA, USA.
authors.forename: James
authors.initials: J
authors.lastname: Dargin
mesh_terms: D000328:Adult; D001569:Benzodiazepines / Q000008:administration & dosage / Q000627:therapeutic use*; D002985:Clinical Protocols; D016638:Critical Illness; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage / Q000627:therapeutic use*; D007362:Intensive Care Units; D007902:Length of Stay; D008140:Lorazepam / Q000008:administration & dosage / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D012121:Respiration, Artificial; D012720:Severity of Illness Index; D013375:Substance Withdrawal Syndrome / Q000175:diagnosis* / Q000188:drug therapy* / Q000628:therapy
chemical_list: D006993:Hypnotics and Sedatives; D001569:Benzodiazepines; D008140:Lorazepam
keywords: alcohol abuse; alcohol withdrawal syndrome; alcohol withdrawal syndrome management; benzodiazepines; critical care