Alcohol Withdrawal Rebuttal

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Nurses Edition Commentary

Mizuho Morrison, DO, Lisa Chavez, RN, and Kathy Garvin, RN

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Whit F. -

One thing nobody talked about much was the use of clonidine for withdrawal symptoms. There's some really good literature out there (admittedly on the older side), but it's worth reading. Clonidine is basically like an oral version of dexmedetomidine, and while it doesn't do much for the hallucinations of DTs or seizures, it's SUPER-helpful for turning down the sympathetic outflow that is really likely to kill a patient. If you've got a patient who can take oral meds and you can't quite get his bp and heart rate down with benzos because of nursing or supply issues, consider adding some clonidine to the mix.

James M., D.O. -

The practice of prescribing benzo's for outpatient treatment of alcohol withdrawal probably has an NNT of infinity. We are treating ourselves with this practice not the patient. I don't do it. If they need immediate treatment I give IV ativan. By the time it wears off they either get help or start drinking. If I were following up with the patient in my clinic that may be different, but I am not.

Geoffrey F. -

Despite last month's talk, in my ICU, I love dexmedetomidine for the treatment of the SYMPTOMS of alcohol withdrawal. I give enough benzo to be sure I'm covering the GABA receptors, but then I let the dex do the heavy lifting. Titratable, no respiratory depression and great for the hypersympathetic stuff without pesky metabolites hanging around to bite you in the butt.

Michael N. H. -

What about IV Phenobarb in ED, then D/C if stable?

"Intravenous phenobarbital for alcohol withdrawal and convulsions.
Young GP, Rores C, Murphy C, Dailey RH.

In a prospective, uncontrolled study, 62 alcoholic patients received IV phenobarbital (IV-PB) to treat the alcohol withdrawal (AW) syndrome. Initially 260 mg of IV-PB were administered followed by 130 mg every 30 minutes to an end point of light sedation. A mean loading dose of 598 (+/- 192) mg of IV-PB resulted in a mean increase in the serum PB level of 13.9 (+/- 4.7) microgram/mL. Thus, the serum PB level rose 1.65 micrograms/mL for each mg/kg of IV-PB administered to these adult patients in AW. Forty-six of 48 tremulous patients (96%) showed improvement in their AW tremors. None of the 38 patients who presented with AW seizures had another convulsion during a mean observation period of three hours and 47 minutes. Transient ataxia or over-sedation occurred in three of 62 patients (5%) and was exacerbated by concurrent ethanol, diazepam, or phenytoin (six of 17), who were excluded from the study. We conclude that IV-PB is a safe and efficacious therapy for mild to moderate AWS, and IV-PB may prevent AW seizures.

[PubMed - indexed for MEDLINE] "

Ken S. -

Those are all really good points. James speaks the truth. We're treating ourselves. That being said, there are people who do want to get sober and when given the support and opportunity they can do real well.

As ER docs this is our decision to make. Do what you can when you can.

Ken Starr MD

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