The Assessment and Management Practices of Acute Alcohol Withdrawal: Results of a Nationwide Survey of Critical Care Pharmacists

Abstract

Background: Alcohol withdrawal occurs commonly but diagnosis and therapies have not been described. Objective: To characterize practices regarding the assessment and treatment of acute severe alcohol withdrawal and describe perceived barriers to therapies. Methods: A random sample of 500 US-based critical care pharmacists received the pretested, electronically distributed questionnaire. Results: 94 (20%) of 471 eligible recipients responded with diverse representation. Manifestations of alcohol withdrawal that were commonly rated as severe were seizures (91.3%), not oriented to person/place/date (84.1%), delusions (73.8%), diastolic blood pressure >110 mmHg (51.7%), inconsolable agitation (50.7%), and tachycardia (50.7%). Scoring tools were considered highly effective for assessing severity by 43 respondents (45.8%). Management protocols existed in 86 (90.5%) institutions. Sixty-eight (72.3%) respondents indicated protocols were used often/routinely for initial management but only 23 (24.5%) for adjunctive therapies (p<0.0001). Agents employed for initial and adjunctive management were benzodiazepines (92.6% and 61.7%, respectively, p<0.0001), clonidine (29.8% and 34%, respectively), haloperidol (26.6% and 33%, respectively), and barbiturates (20.2% and 24.5%, respectively). Adjunctive agents were most commonly added to reduce dosages of benzodiazepines (antipsychotics, barbiturates, alpha-2 agonists), prevent respiratory depression (alpha-2 agonists), prevent or treat autonomic symptoms (alpha-2 agonists), and prevent or treat agitation/delusions (antipsychotics, barbiturates, alpha-2 agonists). Agents with common barriers to use were dexmedetomidine (bradycardia, hypotension, cost), propofol (hypotension, tracheal intubation required), and ketamine (lack of supportive data). Conclusion: Assessment and management strategies of acute severe alcohol withdrawal vary considerably. Benzodiazepines are the mainstay of treatment. Other agents are commonly used to prevent complications from benzodiazepines or treat agitation/delusions.