Alcohol Withdrawal Guidelines

 

VBMC TRAUMA CARE SERVICES GUIDELINE

Alcohol Withdrawal Guideline

This guideline is the Institutional Guideline for VBMC surgical ICU and is based upon: 1)  liberal screening using CAGE followed by 2) regular CIWA scoring every 4 hours for 24 hours (http://www.mdcalc.com/ciwa-ar-for-alcohol-withdrawal/). See nursing and physician components below. Key points:

·                     Everyone gets a single IV dose of thiamine (1 vial)

·                     If high risk for WE/KP or deficiency, activate aggressive replacement strategy of  thiamine/folate/magnesium

·                     Do not use rally packs

·                     Valium load for most patients (Ativan for liver disease)

 

1.    Assess for patients at high risk of alcohol withdrawal as follows: 

CAGE > 2, h/o withdrawal seizures or previous hospitalization for alcohol use disorder.

2. If screen is positive: contact primary team for initiation of CIWA & thiamine/folate supplementation 

3. Initiate Thiamine/Folate Therapy:

□ Thiamine 200mg IV once, then 100mg PO daily x 6 days 

□ Folate 1mg PO daily x 7 days

□ DO NOT utilize IV Rally Packs

□ NOTE: If high-risk for deficiency/WE (prior seizures, prior DTs, ICU admission, cognitive impairment, mental illness, or definitive/presumptive diagnosis of WE), utilize high-dose thiamine, folic acid, and magnesium replacement algorithm:

·         Thiamine 200mg q8h x 72h (PMID 20642790, 12414541, 9719389, 11304071, 21912244)

·         Folic acid 1mg IV once, then 1mg PO x 7 days (PMID 605207, 15745884)

·         Magnesium 4gm IV once over 2 hours, then 2gm IV x 3 days 

(PMID 3544909, 433814, 14080503)

 

4. If documented history of alcohol related seizures or delirium tremens:

□ Diazepam 10mg PO Q8h x 3 doses (Ativan for liver disease)

 

5. Consider Chemical Dependency Consult

 

6. Nursing Orders

□ Complete baseline CIWA then follow the protocol for vital sign frequency and to assess the patient’s need for symptom based treatment.

□ If patient is sleeping, do not wake the patient up to give diazepam/lorazepam or assess the patient’s   CIWA score; Assess the CIWA score when patient awakens.

□ CALL MD parameters: BP ≥ 160/100 or ≤ 80/60; HR ≥ 100 or ≤ 60; RR ≤ 10 or ≥ 20.

□ CALL MD for all CIWA ≥ 15

 

□ Assess patient 15 mins after each benzodiazepine dose for sedation

 

7. Initiate symptom triggered medical management based on CIWA Score:

·       Diazepam (Valium) preferred in most patients

·       Lorazepam (Ativan) if marked liver disease suspected or age >60

 

CIWA Score

Intervention

1-7

None - Mild

·  No medication indicated

·  Continue CIWA q4h

·  If CIWA <8 for 24 hours, discontinue protocol and benzodiazepine orders.

8-14

Moderate

CALL MD before dose if CIWA remains >8 on 3 consecutive assessments (12 hours). 

Standard Patient Population:

·  Diazepam 10mg PO (IV if unable to take PO)

·  Repeat CIWA and VS in 4 hours and dose according to this table

Marked liver disease or patients > 60yo:

·  Lorazepam 2mg PO (IV if unable to take PO)

·  Repeat CIWA and VS in 4 hours and dose according to this table

15-24

Severe

CALL MD for all CIWA ≥ 15

Standard Patient Population:

·  Diazepam 15mg PO (IV if unable to take PO)

·  Repeat CIWA and VS in 2 hours and dose according to this table

Marked liver disease or patients > 60yo:

·  Lorazepam 3mg PO (IV if unable to take PO)

·  Repeat CIWA and VS in 2 hours and dose according to this table

≥25

Very severe

CALL MD for all CIWA ≥ 15. 

·  Activate Rapid Response Team 

·  Diazepam 20mg IV and reassess 15 min after dose for worsening agitation.

·  Repeat CIWA and VS in 30 min. 

After each benzodiazepine dose:

o   Assess @ 15min for signs of sedation. 

 

                  

□ Diazepam (Valium) preferred in most patients

CIWA Score

Medication Orders – Diazepam Protocol

Nursing Orders – Diazepam Protocol

1-7

None - Mild

·  CIWA q4h

·  If CIWA <8 for 24 hours, discontinue protocol and benzodiazepine orders.

8-14

Moderate

Diazepam 10mg PO/IV q4h prn CIWA 8-14

·  Repeat CIWA and VS in 4 hours and dose according to protocol

·  CALL MD before dose if CIWA remains >8 on 3 consecutive assessments (12 hours).

15-24

Severe

Diazepam 15mg PO/IV q2h prn CIWA 15-24

·  Repeat CIWA and VS in 2 hours and dose according to protocol

≥25

Very severe

Diazepam 20mg IV q30 minutes prn CIWA ≥25

·  Activate Rapid Response Team.

·  Reassess 15 minutes after dose given for worsening agitation.

·  Repeat CIWA and VS in 30 min. 

 

□ Lorazepam (Ativan) consider in marked liver disease or age >60

CIWA Score

Medication Orders – Lorazepam Protocol

Nursing Orders – Lorazepam Protocol

1-7

None - Mild

·  CIWA q4h

·  If CIWA <8 for 24 hours, discontinue protocol and benzodiazepine orders.

8-14

Moderate

Lorazepam 2mg PO/IV q2h prn CIWA 8-14

·  Repeat CIWA and VS in 2 hours and dose according to protocol

·  CALL MD before dose if CIWA remains >8 on 3 consecutive assessments.

15-24

Severe

Lorazepam 3 PO/IV q1h prn CIWA 15-24

·  Repeat CIWA and VS in 1 hour and dose according to protocol

≥25

Very severe

Lorazepam not recommended

 

Diazepam 20mg IV q30 minutes prn CIWA ≥25

·   Activate Rapid Response Team.

·  Reassess 15 minutes after dose given for worsening agitation.

·  Repeat CIWA and VS in 30 min.