1. Care of the Patient Experiencing Alcohol Withdrawal Syndrome CIWA Protocol

2. Following this training the nurse will be able to:
1. Recognize patients at risk for alcohol withdrawal syndrome.
2. Rapidly identify early signs of alcohol withdrawal and implement aggressive treatment by utilizing the CIWA protocol.
3. Mitigate withdrawal symptoms with the use of prophylactic medications and interventions.
4. Avoid Alcohol Withdrawal Delirium!
5. Promote patient, team member and physician safety.

3. What is Alcohol Withdrawal Syndrome
Alcohol Withdrawal is defined as: a set of signs and symptoms that develop after a person reduces or stops alcohol consumption after a period of prolonged periods of excessive drinking.

4. What is One Drink? 12 ounces of beer 5 ounces of wine
A shot or 1.5 oz of hard liquor
4 ounces of sherry or a liqueur (Baileys or Kahluha)
Remember, some people drink large volumes such as a 12-pack,
a case, a pint or fifth per day.

5. It’s Important to remember……
If interventions don’t take place early on, withdrawal symptoms are more likely to become more severe and gradually progress to:
Hallucinations
Seizures
Delirium Tremens
Death

6. How Alcohol Works in the Body (Short term)
Every system in the body is affected by alcohol.
Alcohol is absorbed from the stomach and small intestines it passes quickly into the bloodstream.
Within minutes it permeates the brain, liver, heart, lungs, pancreas and kidneys.
Depression of the inhibitory centers of the cerebral cortex occur causing euphoria, exaggerated feelings of well-being, ataxia, loss of self-control and dose related sedation.

7. How Alcohol Works in the Body (long term)
Chronic drinking consistently depresses the Central Nervous System.
The brain compensates by increasing the response of the NMDA (excitatory)receptors and decreasing the GABA-A (inhibitory) receptors
This is why tolerance develops
Abrupt cessation of alcohol leads to a rebound stimulatory effect
Enhanced NMDA receptor function plus dysregulation of dopaminergic system and reduced GABAergic function results in an Increased Excitability of the Nervous System

8. *This is when you see the symptoms manifesting themselves.
So…
Abrupt cessation of alcohol or withdrawal actually produces a rebound effect ▼
A “hyper-excitability” reaction in the brain-results in
alcohol withdrawal syndrome.
Once the depressant effect of alcohol is removed every mechanism
will overreact within hours of the last drink.
*This is when you see the symptoms manifesting themselves.

9. Astute assessment is KEY to avoiding severe withdrawal symptoms.
Minor Withdrawal Symptoms: May occur as soon as – 8 hours after the patient’s last drink.
Symptoms may include and may be very subtle:
Insomnia
Mild anxiety
Headache
GI upset
Tremors
Palpitations
Hypertension
Diaphoresis
Astute assessment is KEY to avoiding severe withdrawal symptoms.

10. Severe Withdrawal Symptoms
Delirium tremens: Worst form of alcohol withdrawal which may occur anytime between hours after their last drink
Medical emergency
Life threatening
Symptoms may last for up to 5-6 days
Signs and symptoms may include:
Hallucinations
Disorientation
Generalized seizures
Pronounced autonomic hyper-reactivity with hypertension, hyperthermia, tachycardia, tachypnea and tremors
Seizures are the highest safety risk for patients in alcohol withdrawal because of the risk of aspiration, oxygen deprivation, and physical injury from thrashing

12. Kindling Phenomena
Occurs when a patient goes through repeated episodes of withdrawal “yo-yo drinking” repeated cycles of intoxication followed by abstinence.
Associated with profound behavioral changes and neurological alterations including brain damage
Alcoholics who experience two or more withdrawals may fall into this category as acute withdrawal symptoms worsen with each withdrawal which precipitates continued alcohol abuse
Failure to manage alcohol withdrawal syndrome appropriately can lead to permanent brain damage or death

13. Withdrawal Protocols at Lake Health
Clinical Institute Withdrawal Assessment for Alcohol (CIWA)
Clinical Institute Withdrawal Assessment for Narcotics (CINA/COWS)

15. Benzodiazepines enhance the effect of the neurotransmitter gamma-aminobutyric acid (GABA) at the GABAA receptor, resulting in sedative, hypnotic (sleep-inducing), anxiolytic (anti-anxiety), anticonvulsant, and muscle relaxant properties.

16. Thiamine levels are often low in alcohol-dependent people, and deficiency of this important vitamin could lead to Wernicke's encephalopathy, a disorder characterized initially by the eyes looking in different directions from each other. If thiamine is given in a timely fashion, this potentially devastating disorder can be completely reversed.
Low magnesium levels can lead to fatal cardiac dysrhythmias such as ventricular tachycardia in the form of Torsades Des Points and ventricular fibrillation

17. NURSING DOCUMENTATION

18. CIWA Protocol and VS Frequency
>6 hourly VS
>8 hourly VS
>20 hourly VS
Signs of excitation

19. Nursing Interventions
Decrease patient stimulation by attempting to place patient in a private room
Maintain a quiet environment
Place alarms on privacy
Close window blinds
Turn down lighting
Limit visitors
Quietly instruct patient on care routines
Avoid restraints
If the patient is deemed a risk for self-harm (suicide assessment, psycho social tab).
Immediately place a sitter at the bedside, notify physician, request behavioral health social work consult.
Inform the sitter of goal to maintain a calm, cooperative and safe environment.
Sitter to complete environment of care checklist every shift and prn.
Sitter to complete sitter checklist every 15 minutes.
Nurse will complete every 4 hour suicide flowsheet.
ONLY a physician may discontinue suicide precautions.

20. Consistent Assessment and Dosing are Key to a safe withdrawal
Because it takes several days for the neurotransmitters equilibrium to be readjusted, patients must be medicated consistently during the entire withdrawal period as indicated by the CIWA scale.
Accurate and consistent assessments and protocol/order compliance is essential to the successful outcome for the patient on a CIWA protocol.
Recognize early. Treat with evidence based protocol. Maintain patient and team member safety.

21. Questions