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. |