Alcohol Withdrawal

Published on 07/03/2015 by admin

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Last modified 07/03/2015

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Chapter 65 Alcohol Withdrawal

Bruce A. Crookes, MD, FACS , William Peery, MD

1 What are alcohol use disorders (AUDs)?

AUDs are a spectrum of disorders that range from excessive use, to abuse, to dependence, to addiction.

Abuse is defined as being when an individual has adverse socioeconomic or health consequences related to the use of a substance.

Dependence is manifested when a patient has withdrawal symptoms when the substance is discontinued or when larger amounts are required to obtain the same effect.

Addiction is present when the individual has a compulsive craving for the substance. It is important to realize that, at any one time, an individual may be experiencing a combination of abuse, dependence, and/or addiction.

2 How much alcohol is too much? How big a problem is it in the intensive care unit (ICU)?

The National Institutes of Health has published guidelines that serve to quantify and define excessive alcohol use. Men aged ≤65 years are thought to have excessive alcohol consumption if they consume more than four drinks per day or more than 14 drinks in a week. For men >65 years and for women, these volumes are halved. It is thought that patients who consume excessive amounts of alcohol are at increased risk for health problems. It has been estimated that AUDs are seen in as many of 15% to 20% of primary care and hospitalized patients, in 10% to 33% of ICU admissions, and in approximately 50% of trauma patients.

3 Are AUDs associated with any alterations in patient outcomes?

The outcomes of patients with AUDs appear to vary by the reason for admission. Trauma patients with AUDs seem to have no difference in mortality or length of stay as compared with controls, although trauma patients with a history of chronic alcohol abuse have a higher incidence of pneumonia and cardiac complications. Burn patients with AUDs have higher mortality and poorer shorter and long-term outcomes. Surgical patients are at greater risk for pneumonia, wound infections, sepsis, poor wound healing, and cardiac complications. In the medical ICU, AUDs increase the need for mechanical ventilation and are independent risk factors for sepsis.

4 How is immune function altered by alcohol ingestion?

Neutrophil and macrophage response is altered by the ingestion of alcohol, and leukopenia may result from depressed levels of granulocyte colony-stimulating factor. In surgical and trauma patients, aberrant cytokine concentrations have been noted, including decreased levels of interleukin (IL)-1, IL-6, IL-12, tumor necrosis factor-α, and interferon-β. Overall, in surgical and trauma patients, an imbalance appears to exist between proinflammatory cytokines and antiinflammatory cytokines.

5 What are the criteria for alcohol withdrawal, and when does it typically occur?

First, the patient must have cessation of (or reduction in) alcohol use that has been heavy and prolonged. In addition, the patient must have two or more of the following, developing several hours to a few days after cessation: autonomic hyperactivity (i.e., sweating or heart rate >100 beats/minute); increased hand tremor; insomnia; nausea or vomiting; transient visual, tactile, or auditory hallucinations or illusions; psychomotor agitation; anxiety; and grand mal seizures, typically tonic-clonic in nature. Alcohol withdrawal typically manifests itself 48 to 96 hours after abstinence from alcohol.

6 What is delirium tremens (DTs)? What is the mortality associated with DTs in the ICU?

According to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, fourth edition, DTs is alcohol withdrawal and associated with either a:

Disturbance of consciousness (i.e., reduced clarity of awareness in the environment) with reduced ability to focus, sustain, or shift attention; delirium; confusion; and frank psychosis

Change in cognition (such as memory deficit, disorientation, language disturbance)

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