Withdrawal from alcohol is a serious and common complication associated with hospitalization that can result in the condition known as delirium tremens. Many patients who consume alcohol cease drinking on or prior to admission for both voluntary and involuntary reasons.
A patient does not need to be an alcoholic by medical definition to be at risk for this alcohol withdrawal syndrome. Patients who drink as little as two drinks per day have been known to develop delirium tremens. Additionally, chronic benzodiazepine users are also at risk for the same syndrome, since this class of drugs affects the same receptors in the brain.
Delirium tremens Signs And Symptoms
Delirium tremens is a constellation of signs and symptoms that include confusion, agitation, delirium, combativeness, hallucinations (commonly visual changes involving bright lights and colour), and potential seizure activity. These responses put patients at risk for self-injury as well as injury to staff and others.
Additionally, these patients exhibit surges of sympathetic output resulting in tachycardia, hypertension, profuse sweating, and mydriasis. Patients with concomitant cardiovascular disease are at risk for myocardial infarction, intracerebral hemorrhage, and stroke. Even with treatment, delirium tremens carries a mortality risk of approximately 10%.
Delirium tremens Treatment
One way to prevent delirium tremens is to have the patient continue alcohol consumption. While it is desirable to treat someone for alcoholism, abrupt cessation is not the answer in the acute hospitalization period when other medical or surgical concerns are paramount.
If the patient is able to drink liquids or has an enteral feeding tube (e.g., nasogastric tube, orogastric tube, percutaneous endoscopic gastronomy tube) and there are no other contraindications to enteral feeding, the easiest way to prevent delirium tremens is simply to give the patient alcohol.
Many hospitals stock beer or spirits either in their pharmacy or as part of their food service system and these may be prescribed for the patient deemed at risk of developing this. Limited amounts will suffice, generally one to two beers or the equivalent in spirits or wine (one 12-ounce beer is equal to 5.5 ounces of wine or 1.5 ounces of spirits such as vodka or whiskey assuming a proof of 80) with meals.
This will not lead to overt intoxication, particularly in someone who normally consumes much larger amounts. Blood alcohol levels can be measured, however, if there is such a concern. If enteral feeding is not an option, ethanol can be infused intravenously. It is usually ordered as 10% ETOH to be run at a rate of 20 to 40 cc/hr. Like enteral alcohol, this in most cases will prevent withdrawal and delirium tremens without leading to overt intoxication.
Alternatively, if the pharmacy cannot or will not make an ethanol infusion and enteral ethanol is not an option, benzodiazepines are the preferred alternative method of preventing ethanol withdrawal. These may be given enterally or intravenously. Lorazepam is commonly employed because of its lack of active metabolites and an intermediate duration of action, but most drugs in this class will work effectively.
Benzodiazepines may be given on an around-the-clock (ATC) or as needed (prn) basis. Doses commonly used are 2 to 4 mg every 4 to 8 hours or prn. Recent literature suggests that while the ATC method is most commonly employed, treating the emergence of symptoms prn with benzodiazepines is just as effective at preventing and treating delirium tremens and will minimize complications while at the same time reducing length of stay.
Despite prophylaxis, a certain percentage of patients may still progress to withdrawal and delirium tremens. Once this has occurred, any ethanol being given enterally or by intravenous infusion should be abandoned (ethanol is not effective in treating the symptoms of delirium tremens) and benzodiazepines substituted.
The intravenous form is preferred to ensure administration since withdrawal may include symptoms of nausea and vomiting, impeding enteral absorption. Once the delirium tremens has started, doses of benzodiazepines equal to or higher than prophylaxis are used. Sometimes, very large doses or continuous infusions are necessary. Once the withdrawal syndrome is under control, these should be weaned slowly so as to avoid reemergence of withdrawal.
Additional agents to consider are clonidine and haloperidol. Clonidine 0.1 mg orally every 8 hours is very effective in blunting the sympathetic surge associated with ethanol withdrawal and as such may help prevent complications such as myocardial infarction in those at risk.
Beta-1 specific blockers may also be used to block end-organ responses if tachycardia is a threat but this may have little effect on blood pressure secondary to alpha-1 agonism, which may need to be treated with separate agents.
Haloperidol is effective in providing sedation and ameliorating some of the hallucinations that occur. An electrocardiogram should be checked each day to watch for long QT syndrome when the patient is getting haloperidol. Treatment for this is cessation of haloperidol and magnesium supplementation.
One final note is that many patients hide or do not admit to their alcohol use and their families may not be aware of the extent of their use. Delirium tremens should be in the differential for any patient experiencing mental status change, especially when coupled with signs of sympathetic activity.
References
Ebell MH. Benzodiazepines for alcohol withdrawal. Am Fam Physician 2006;73:1191.
McIntyre J, Hill KR, Woodside J Jr. Alcohol withdrawal syndrome. Am Fam Physician 2004;69:1443.
Sanouri I, Dikin M, Soubani AO. Critical care aspects of alcohol abuse. South Med J 2005;98:372 and 381.