Describe the incidence and complications of alcohol withdrawal in the trauma Evaluate the efficacy and appropriateness of the Clinical Institute for Withdrawal Assessment CIWA in the trauma populati ID: 823229
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SAFETY & EFFICACY OF CIWA IN THE TRAUMA
SAFETY & EFFICACY OF CIWA IN THE TRAUMA POPULATIONDoug Oyler, PharmD, BCCCPClinical Pharmacist Surgical/Trauma Critical CareUK HealthCareDescribe the incidence and complications of alcohol withdrawal in the trauma Evaluate the efficacy and appropriateness of the Clinical Institute for Withdrawal Asses
sment (CIWA) in the trauma populationAL
sment (CIWA) in the trauma populationALCOHOL WITHDRAWAL SYNDROME (AWS)Up to 50% of trauma patients present with acute alcohol intoxicationvelop AWSScreening for alcoholism: CAGE criteriaHave you felt you need to DOWN?Are you ANNOYEDby discussion of your drinking?Have you felt GUILTYHave you needed an t
o start the day?BilelloJ, et al. World
o start the day?BilelloJ, et al. World J Surg2011; 35: 2149-53Imae credit: https://americanaddictioncenters.or/withdrawal-timelines-treatments/alcohoCLINICAL INSTITUTE FOR WITHDRAWAL ASSESSMENT10-item scale assessing: nausea/vomiting, tremor, diaphoresis, anxiety, agitation, tactile disturbances
, auditory disturbances, visual disturba
, auditory disturbances, visual disturbances, headache, disorientationItems assessed independently, 0-67 points0-15: mild AWS16-20: moderate AWS�20: severe AWSAllows for symptom-based treatment (with benzodiazepines), which is associated with improved outcomeWell-validated in medicine population
JawaRS,etaŽ.AJSurg2014
JawaRS,etaŽ.AJSurg2014;20ͺ:7ͺ1CIWA CONSIDERATIONS IN TRAUMAPotential overlap of symptoms with physiologic manifestations of traumaImproper screening up front for many Concomitant use of benzodiazepines with opioid analgesics creates synergistic respiratory depressionassociated with
10X increase in deathSun EC, et al. . 2
10X increase in deathSun EC, et al. . 2017;356:j760Imae credit: https://www.druabuse.ov/drus-abuse/oioids/benzodiazeSTUDYEvaluation of CIWA-based management of trauma vs. medicine patientsHypothesis = trauma patients receive more benzodiazepines with subsequent UK HealthCareACS Level I trauma
center, verified 30 years4,000 annual t
center, verified 30 years4,000 annual trauma visits (~18% pediatric)~18% pediatric~20% ISS Retrospective chart review of patients admitted to trauma/orthopedic fracture (intervention) or medicine (control) service lines who received CIWA-based treatment for suspected AWS.Exclusion criteria: , active I
CU status or GCSverbalA orderPrimary end
CU status or GCSverbalA orderPrimary endpoint: cumulative benzodiazepine use pursuant to CIWA orderSecondary endpoints: median CIWA score, percent of CIWA scor&#x 4 a;&#xt in;&#xitia;&#xtion;&#x of ;IW7;.10;es 8, concomitant opioid use, adverse effects related to treatment (e.g., respiratory de
pression, etc.)DEMOGRAPHICSVariableTra
pression, etc.)DEMOGRAPHICSVariableTrauma/ORFAge, years49.950.4Male gender261(72.3%)96 (81.4%)History of seizure*76 (21.1%)8 (6.8%)Historyof cirrhosis19 (5.3%)2 (1.7%)History of chronickidney disease*21 (5.8%)1 (0.8%)History of chronicbenzodiazepine use94 (26.0%)25 (21.2%)History of chronic opioid use
119(33.0%)35 (29.7%)History of chronicop
119(33.0%)35 (29.7%)History of chronicopioid & benzodiazepine use49 (13.6%)16 (13.6%)Admission GlasgowComa Scale score*14.614.1RESULTSVariableTrauma/ORFCumulative benzodiazepinedose, mg diazepam equivalent*69.932.4Patientsreceiving no benzodiazepine, %*31.943.2CIWAScore � 8, % of total*19.89.7C
umulative opioid dose, mgmorphine equiva
umulative opioid dose, mgmorphine equivalent*69.0140.9In-hospitalmortality, %4.71.7Median hospital LOS, days4.63.9Patients requiring naloxone, %1.70.0Patientswith rapid response activation, %*27.716.1Patients requiring ICU transfer, %*11.63.4COMPLIANCE WITH CIWAPROTOCOLTRAUMA/ORFp RESULTS SUMMARYSick
er patients in the medicine cohort had m
er patients in the medicine cohort had more complicationsMedicine patients generally had more severe AWSSignificantly more patients in the trauma cohort received no benzodiazepinePatients in the trauma/ORF cohort received significantly more opioidsBenzodiazepine correlation with CIWA was different in th
e trauma cohortCIWA may be appropriate
e trauma cohortCIWA may be appropriate for use in the trauma population, but better screening is likely neededConsidering co-administered opioids is importantVariance in compliance rates warrant further investigationSAFETY & EFFICACY OF CIWA IN THE TRAUMA POPULATIONDoug Oyler, PharmD, BCCCPdoug.oyler@