Clinical Institute Withdrawal Assessment for Alcohol150Revised might b - PDF document

1 Clinical Institute Withdrawal Assessment
Clinical Institute Withdrawal Assessment for Alcohol–Revised might be an unreliable tool in the management of alcohol withdrawal Leslie Lappalainen he Clinical Institute Withdrawal Assessment for Alcohol–Revised (CIWA-Ar) protocol (method of treating alcohol withdrawal in our institution and it is frequently used by family physicians. Although various rating scales for alcohol withdrawal have been described, the CIWA-Ar protocol managing withdrawal with benzodiaze Although the CIWA-Ar protocol was vali Case A 57-year-old Polish man presented to an urban hospital at 12:18 PM after falling while intoxicated. His Glasgow Coma Scale score was 11 and his serum ethanol level was 75 mmol/L at 3:53 PM by the neurosurgery department, the patient was kept for - PM with an initial score of 13. Upon reassessment at 7:41 AM department was initiated. The patient’s withdrawal contin - ued to worsen, and lorazepam was switched to diazepam. PM Consult Team (AMCT) was requested. PM 30 hours into the withdrawal process and 21 hours since starting the CIWA-Ar protocol. The patient had received to exhibit signs of severe alcohol withdrawal including tremor. He was unable to converse in English, although he was able to speak Polish when a telephone translation tory, with no previous admissions, no pharmacy records, no next of kin available, and a retired family physician clubbing, palmar erythema, and a palpable liver. Given the patient’s inability to converse, the AMCT discontinued the CIWA-Ar protocol and constructed an OAWS ( VOL 63: SEPTEMBER SEPTEMBRE 2017 Canadian Family Physician Le Médecin de famille canadien 691

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Because of the apparent liver disease, diazepam was changed to 1 mg of oral lorazepam (which does not require hepatic oxidation) 4 times a day, with lorazepam as needed based on the OAWS. The patient’s withdrawal improved and his lorazepam requirements gradually declined. On day 4, scheduled lorazepam was decreased to 3 times a day, then to twice a day on day 5. The patient remained hypertenOAWS and treatment with lorazepam was discontinued and the patient vided to the patient’s Polish-speaking family physician regarding relapse Discussion An important limitation of the CIWA-Ar is its heavily subjective nature. Only 3 of 10 components (tremor, paroxysmal sweats, agitation) can be rated by sion with the patient. Given that benzodiazepines are provided based on the CIWA-Ar score, there is risk of incorrect dosing when scores are unreliable, which harbours potential for patient harm. There are 2 primary reasons why the CIWA-Ar was unreliable in this case. First, there was a substantial ing. This became clearer as the patient’s withdrawal improved and he was available, CIWA-Ar might remain impractical, as it requires frequent reassessments and would necessitate 24-hour interpreter coverage. The second limitation of the CIWA-Ar was subtler; the patient was confused and disoriented, so even in the absence of a communication barrier, his responses While this case illustrates 2 reasons to use an OAWS, other common posed for inpatient management of alcohol withdrawal, but like the CIWA-Ar, they often require a reliable history.sented here has proved reliable for treatment of complex alcohol Objective alcohol withdrawal scale withdrawalSc

3 orepressure≥160pressure≥90rate≥90-
orepressure≥160pressure≥90rate≥90-tremor;-diaphoresis;≥2orallorazepam10≥3orallorazepamscore<2measures,reassesshourshours,hourshours,VOL 63: SEPTEMBER SEPTEMBRE 2017 Canadian Family Physician Le Médecin de famille canadien Canadian Family Physician Le Médecin de famille canadien VOL 63: SEPTEMBER SEPTEMBRE 2017 �� Figure 1. The Clinical Institute Withdrawal Assessment for Alcohol–Revised scale Reproduced from Sullivan et al. Case Report withdrawal by a busy AMCT in a tertiary Canadian hospital. The OAWS in alternative to the CIWA-Ar and therefore has not been validated as such. Rather, it is an approach to treatment be modied to t the clinical situation. For example, in a sure could be excluded or a higher blood pressure cutoff chosen. Similarly, heart rate might be excluded for or parkinsonism. Additionally, the OAWS can be modied by changing the cutoff for scores prompting doses of benzodiazepines. In this case, the patient was unwell to minimize underdosing. In more moderate withdrawal or where there was concern for benzodiazepine toxicity, cutoffs of 3 or more, or 4 or more, would be more benConclusion The OAWS can be useful for cases of alcohol withdrawal in which the CIWA-Ar is unreliable. The OAWS can be used as a framework and tailored to individual cases with consideration of comorbidities and withdrawal severity. is a family physician and addiction medicine physician in Winnipeg, Man. At the time of this case she was a clinical fellow in the St Paul’s Hospital Goldcorp Addiction Medicine Fellowship program in Vancouver, BC.Lead for Addiction Medicine, Mental Health and Substance Use for the Interior Health Authority in British Columbia and a clinical instructor in the Department of Family Medicin

4 e at the University of British Columbia
e at the University of British Columbia in Vancouver. At the time of this case she was an addiction medicine physician at St Paul’s Hospital in Vancouver. Competing interests Correspondence eknight@exchange.hsc.mb.ca References Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). Br J AddictBayard M, McIntyre J, Hill KR, Woodside J Jr. Alcohol withdrawal syndrome. PhysicianHecksel KA, Bostwick JM, Jaeger TM, Cha SS. Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general hospital. Mayo Clin ProcWilliams D, Lewis J, McBride A. A comparison of rating scales for the alcohol-withdrawal syndrome. Daeppen JB, Gache P, Landry U, Sekera E, Schweizer V, Gloor S, et al. Symptom-triggered vs xed-schedule doses of benzodiazepine for alcohol withdrawal: a randomArch Intern MedReoux JP, Miller K. Routine hospital alcohol detoxication practice compared to symptom triggered management with an objective withdrawal scale (CIWA-Ar). Jaeger TM, Lohr RH, Pankratz VS. Symptom-triggered therapy for alcohol withdrawal Sullivan JT, Swift RM, Lewis DC. Benzodiazepine requirements during alcohol withdrawal syndrome: clinical implications of using a standardized withdrawal scale. J Clin PsychopharmacolMcPherson A, Benson G, Forrest EH. Appraisal of the Glasgow assessment and management of alcohol guideline: a comprehensive alcohol management protocol for use in general hospitals. Repper-DeLisi J, Stern TA, Mitchell M, Lussier-Cushing M, Lakatos B, Fricchione GL, et al. Successful implementation of an alcohol-withdrawal pathway in a general PsychosomaticsVOL 63: SEPTEMBER SEPTEMBRE 2017 Canadian Family Physician Le Médecin de famille canad