7: Managing withdrawal Objectives

7: Managing Alcohol Withdrawal
This presentation gives a brief overview of alcohol withdrawal relating to Chapters 8 & 9.1 in the Clinical guidelines for nursing and midwifery practice in NSW: Identifying and responding to drug and alcohol issues: NSW Department of Health 2007. This presentation can be used in full or part there of. It was developed to provide a example of a brief presentation on the topic. Please encourage the participants as much as possible to contribute to the presentation. Also encourage them to read the full text in Chapters 8 & 9.1 to gain a fuller understanding as this presentation is only a brief overview. Further information on alcohol withdrawal management should be obtained from the NSW Health Clinical Withdrawal Guidelines. Prepared by J. Mabbutt & C. Maynard NaMO September 2008

7: Managing withdrawal Objectives
1. During the session nurses & midwives will learn how to identify, assess & manage a patient in alcohol withdrawal 2. By the end of the session nurses & midwives will have an understanding or use of the AWS/CIWAR-Ar withdrawal scales 3. At the end the session, nurses & midwives will have a basic understanding & knowledge to safely & effectively identify, monitor & manage alcohol withdrawal Read out the objectives. Encourage the participants to be as actively involved in the session as possible for example asking questions.

7: Managing withdrawal Effective management of withdrawal in its early stages can reduce or prevent progression to complicated withdrawal Complicated withdrawal may be life-threatening due to: Accidental injury, dehydration, electrolyte imbalance, seizures, delirium tremens, or the negative impact on other concurrent disorders, including acute infection, renal disease or diabetes These are some of the key principles of withdrawal with key words emphasised. Go through each point. Ask for any comments or questions.

7: Indications and guidelines: Assessing withdrawal
Severe alcohol withdrawal is potentially life threatening The most important thing is to anticipate when it may occur & to suspect it when an unexplained acute organic brain syndrome is detected Before continuing to assess alcohol withdrawal, the following information focuses on a form of brain injury called the Wenicke’s-Korsakoff syndrome These are some more key principles of alcohol withdrawal. Alcohol withdrawal is potentially life threatening is a very important fact to stress to participants. Mention the prevalence of alcohol use in the community and the high amount of people who are admitted to hospital for alcohol withdrawal. It is important to always assess for alcohol and other drug use. Go through each point. Ask for any comments or questions.

7: Indications and guidelines: Complications of misuse – Wernicke-Korsakoff syndrome (1)
This is a form of brain injury resulting from thiamine deficiency, which complicates alcohol dependence If not treated early it can lead to permanent brain damage & memory loss – young alcohol-dependent people are at risk Signs & symptoms of Wernicke’s encephalopathy, which is usually the first stage of the syndrome, are: Ophthalmoplegia (reduced eye movements or nystagmus) Ataxia & confusion The Wernicke-Korsakoff syndrome is a very important clinical issue. Patients at risk of alcohol withdrawal may present with this syndrome. People who are alcohol dependent and have poor nutritional intake are especially at risk of this syndrome. Highlight the signs and symptoms and that these may be confused with other syndromes or assumed to be just part of alcohol withdrawal alone. This is an issue especially for Emergency Departments with the key management issues on the next slide. Ask for any comments or questions.

7: Indications and guidelines: Complications of misuse – Wernicke-Korsakoff syndrome (2)
This condition is reversible if recognised and treated with parenteral vitamin B1 Parenteral thiamine should be administered before any form of glucose Glucose in the presence of thiamine deficiency risks precipitating Wernicke’s encephalopathy Stress the importance of giving IV thiamine before any form of glucose. Go through each point. Ask for any comments or questions.

7: Indications and guidelines: Assessing withdrawal – Onset & duration of alcohol withdrawal (1)
Onset of alcohol withdrawal is usually 6-24 hours after the last drink Consumption of benzodiazepines or other sedatives may delay the onset of withdrawal In some severely dependent drinkers, simply reducing the level of consumption may precipitate withdrawal, even if they have consumed alcohol recently These are some more key points of alcohol withdrawal assessment. Go through each point. Highlight the possibility of delaying alcohol withdrawal in point two. Also withdrawal can happen with a reduction of regular use. This is a key principle in any drug use. Ask for any comments or questions.

7: Indications and guidelines: Assessing withdrawal – Onset & duration of alcohol withdrawal (2)
Usually withdrawal is brief & resolves after 2-3 days without treatment; occasionally, withdrawal may continue for up to 10 days Withdrawal can occur when the blood alcohol level is decreasing, even if the patient is still intoxicated These are some more key points of alcohol withdrawal assessment. Go through each point. The final point regarding alcohol withdrawal occurring even when the patient is still with a BAL is very important to stress. Ask for any comments or questions.

Figure 9.1: Progress of alcohol withdrawal syndrome
This figure is an excellent illustration of the alcohol withdrawal syndrome. Please highlight the different types of withdrawal periods. Seizures will generally occur in the first couple of days. The delirium tremens occur later in the withdrawal during the severe withdrawal period. Stress the risk of death in untreated severe withdrawal. Ask for any comments or questions. Figure 9.1: Progress of alcohol withdrawal syndrome

7: Indications and guidelines: Assessing withdrawal – Index for Suspicion of Alcohol withdrawal (1)
Severity of alcohol withdrawal ranges from mild to severe The following questions, known as the Index for Suspicion of Alcohol Withdrawal, will help you determine whether the patient is likely to move into alcohol withdrawal: A regular intake of 80 grams (8 drinks-Males) or 60 grams (6 drinks-Females) of alcohol or more per day? Taken even smaller amounts of alcohol in conjunction with other CNS depressants? Previous episodes of alcohol withdrawal? These are the key indicators for alcohol withdrawal known as the Index of Suspicion. Go through each point – stress this different between risk with men and women. Ask for any comments or questions.

Current admission for an alcohol-related reason? Physical appearance indicate chronic alcohol use: parotid swelling (swelling in the gland under the ear) cushingoid face (full/moon looking face) facial telangiectasia (red spots/blood vessels) eyes reddened or signs of liver disease ascites, jaundice, limb muscle wasting These are some more key indicators for alcohol withdrawal known. Go through each point Ask for any comments or questions.

Pathology results show raised serum GGT Raised mean cell volume (MCV) Displaying symptoms such as anxiety, agitation, tremor, sweatiness or early morning retching, which might be due to an alcohol withdrawal syndrome? These are some more key indicators for alcohol withdrawal known. The GGT is a liver enzyme which can be raise in some one regularly using alcohol use. It is not a definite test and can be due to other causes. The MCV can be raised due to the alcohol effecting the bone marrow’s production of red blood cell. They are released more immature and larger. Ask for any comments or questions.

7: Indications and guidelines: Signs & symptoms of alcohol withdrawal (1)
Alcohol withdrawal is a syndrome of central nervous system hyperactivity characterised by symptoms that range from mild to severe The symptoms and signs of alcohol withdrawal may be grouped into three major classes: See Table 9.4 Highlight that alcohol and (other depressant drug withdrawal) is characterised by central nervous system hyperactivity/hyperstimulation. Ask for any comments or questions.

Autonomic overactivity Gastrointestinal Cognitive & perceptual changes
Sweating Anorexia Anxiety Tachycardia Nausea Vivid dreams Hypertension Vomiting Illusions Insomnia Dyspepsia Hallucinations Tremor Delirium Fever Before showing this slide, you may ask participants what are the symptoms of alcohol withdrawal and write these up on the white board, if there is time you could break them into small groups. Then go through the signs and symptoms on the table. The CIWAR-Ar clinical videos on alcohol withdrawal in the CD Rom give examples of alcohol withdrawal signs and symptoms. The full version of the CIWAR-Ar videos is available on the site below. You may wish to ask the participants what basic nursing / midwifery care strategies they could use to deal with these signs and symptoms. Remind them that many people can be managed in alcohol withdrawal without medications. If time permits, you may ask them as a whole group or in small groups ‘what could you so to alleviate these signs and symptoms without medication’. Ask for any comments or questions. Table 9.4: Main signs & symptoms of alcohol withdrawal

Seizures occur in about 5% of patients withdrawing from alcohol They occur early (usually 7-24 hours after the last drink), are grand mal in type (i.e. generalised, not focal) & usually (though not always) occur as a single episode Delirium tremens (“the DTs”) is rare & is a diagnosis by exclusion It is the most severe form of alcohol withdrawal syndrome, & a medical emergency Refer back to the figure on alcohol withdrawal and when seizures are more likely to occur. Highlight that the DTs are a medical emergency. Ask the participants if any of them have nursed someone with the DTs, ask them about how it was managed, what was the outcome and what they would do differently next time. Ask for any comments or questions.

DT’s usually develops 2-5 days after stopping or significantly reducing alcohol consumption The usual course is 3 days, but can be up to 14 days Its clinical features are: Confusion & disorientation Extreme agitation or restlessness – the patient often requires restraining These are some more key factors regarding the DTs. Again stress that they occur later in the withdrawal syndrome. Ask for any comments or questions.

Gross tremor Autonomic instability (e.g. fluctuations in BP & pulse), disturbance of fluid balance & electrolytes, hyperthermia Paranoid ideation, typically of delusional intensity Distractibility & accentuated response to external stimuli Hallucinations affecting any of the senses, but typically visual (highly coloured, animal form) You could ask participants how they would management someone with such symptoms. The could be a group brain storm out participants could be broken into groups. An example of severe withdrawal is demonstrated in ‘when good patients go bad’ on the CIWA-Ar CD clinical case video study Ask for any comments or questions.

7: Indications and guidelines: Alcohol withdrawal scales (1)
The most systematic & useful way to measure the severity of withdrawal is to use a withdrawal scale These provide a baseline against which changes in withdrawal severity may be measured over time Research shows that the use of scales minimises both under-dosing & overdosing with benzodiazepines for alcohol withdrawal syndromes You may ask participants what alcohol withdrawal scales they have use and how they found them, where they helpful. Outline that doing a withdrawal scale will give a good indication of whether the patient is getting better or worse and as noted decreases over and under dosing of medication. Go through each point. Ask for any comments or questions.

There has been considerable debate about the application of withdrawal scales Two different scales, the Alcohol Withdrawal Scale (AWS) and the Clinical Institute Withdrawal Assessment for Alcohol (revised) (CIWA-Ar) are both are recommended for use (see Appendices 2 and 3) Being familiar with the alcohol withdrawal scale used in your local area is a priority Handout the withdrawal scale relevant to what is used in the local area. Also hand out a copy of the one that is not used, for comparison. Stress that both are recommended for use by the NSW Health Clinical Withdrawal Guidelines. The CIWAR-Ar CD-Rom does however only deal with the CIWAR-Ar not the AWS. The CIWAR-Ar is a validated tool and the AWS although widely used and approved for use, but has not be validated. Ask for any comments or questions.

Note that withdrawal scales do not diagnose withdrawal, but are merely guides to the severity of an already diagnosed withdrawal syndrome The nurse or midwife should re-evaluate the patient to ensure that it is alcohol withdrawal & not another condition that is being measured, particularly if the patient does not respond well to treatment Go through and stress these point. Highlight again the risk of another cause for the sign and symptoms. Go through the withdrawal scale and ask participants what else could be caused by the symptoms. Remind them to always be looking for other causes as there is a real risk that the alcohol withdrawal will only be focused on. Ask for any comments or questions.

7: Alcohol withdrawal scales Clinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (1) The CIWA-Ar (see Appendix 2) is a 10-item scale that can be administered as part of supportive care Several studies have shown that the CIWA-Ar scale is a valid, reliable & sensitive instrument for assessing the clinical course of simple alcohol withdrawal State the CIWAR-Ar will be focused on first. Ask them to have that in front of them (these CIWAR-Ar slides may be optional depending on time and what local withdrawal scale is used). Go through each point. Ask for any comments or questions.

7: Alcohol withdrawal scales Clinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) – Videos Video options show either of the following from the CIWA-Ar CD ROM E5 Using the CIWA-Ar alcohol withdrawal scale (withdrawal symptoms are demonstrated) (10.37 min) E8 – A Case study The CIWAR-Ar CD-Rom is an excellent resource to use to learn more about alcohol withdrawal and related issues and see videos demonstrating someone in withdrawal. E5 video is an excellent one that shows what alcohol withdrawal is and how to administer the CIWAR-Ar. E8 video shows the patient outcomes if a poor D&A history is taken compared to when a good history is taken Discuss the video afterward and what nursing / midwifery related issues have come out of watching them. You could ask - what would be the key points to remember? Ask for any comments or questions.

7: Alcohol withdrawal scales Clinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (2) This scale allows a quantitative rating (from 0 to 7 with a maximum possible score of 67) of the following components of withdrawal: Nausea & vomiting Tremor Paroxysmal sweats Anxiety This outlines the items on the CIWAR-Ar. Go through each point. Ask for any comments or questions.

7: Alcohol withdrawal scales Clinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (3) Agitation Tactile disturbances Auditory disturbances Visual disturbances Headache and fullness in head Orientation & clouding of sensoria This further outlines the items on the CIWAR-Ar. Go through each point. Ask for any comments or questions.

7: Alcohol withdrawal scales Clinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (4) Using the CIWA-Ar in presentation to the emergency department: Monitor the patient hourly for at least 4 hours using the CIWA-Ar Contact the medical officer or drug & alcohol nurse practitioner for assessment and monitor hourly if: the alcohol score increases by at least 5 points over this 4-hour period, or the CIWA-Ar total score reaches 10 This outlines the scoring regime for the CIWAR-Ar in Emergency Departments. Stress the need to do it hourly as noted and contacting a medical officer. Ask why this may be so? Highlight the need to stop the alcohol withdrawal increasing in severity, which it can do very quickly in 4 hours so at least hourly monitoring is needed. You can use the analogy of a snow ball rolling down the hill it is better to stop at the top of the hill, it is very hard to stop down the bottom of the hill due to the momentum. In alcohol withdrawal’s cause, the patient is so hyper stimulated and is very hard to control in severe withdrawal. Go through each point. Ask for any comments or questions.

7: Alcohol withdrawal scales Clinical Institute Withdrawal Assessment for Alcohol Revised Version (CIWA-Ar) (5) Using the CIWA-Ar for hospitalised patients: Monitor the patient 4-hourly, using the CIWA-AR, for at least 3 days If the total score reaches 10, monitor hourly & notify the medical officer or drug & alcohol nurse practitioner As per previous slide in a non ED environment. Ask for any comments or questions.

7: Alcohol withdrawal scales Alcohol withdrawal scale (AWS) (1)
The AWS (see Appendix 3) is a widely used scale in NSW If a patient’s history or presentation suggests possible withdrawal, the patient’s condition must be monitored & documented Next the AWS will be focused on. Ask them to have that in front of them (these AWS slides may be optional depending on time and what local withdrawal scale is used) Go through each point. Ask for any comments or questions.

The AWS (see Appendix 3) is a widely used scale in NSW and is a 7 item scale that allows a quantitative rating (from 0 to 4) of the following components: Perspiration Tremor Anxiety Agitation Axilla temperature Hallucinations Orientation This outlines the items on the AWS. Go through each point. Ask for any comments or questions.

Using the AWS in presentation to the emergency department: Monitor the patient hourly for at least 4 hours using the AWS Contact the medical officer or drug & alcohol nurse practitioner for assessment & monitor hourly if: the alcohol score increases by at least 5 points over this 4-hour period, or the AWS total score reaches 5 This outlines the scoring regime for the AWS in Emergency Departments. Stress the need to do it hourly as noted and contacting a medical officer. Ask why this may be so? Highlight the need to stop the alcohol withdrawal increasing in severity, which it can very quickly in 4 hours so at least hourly monitoring is needed. You can use the analogy of a snow ball rolling down the hill it is better to stop at the top of the hill, it is very hard to stop down the bottom of the hill due to the momentum. In alcohol withdrawal’s cause, the patient is so hyper stimulated it is very hard to control them in severe withdrawal. Go through each point. Ask for any comments or questions.

Using the AWS for hospitalised patients: Monitor the patient 4-hourly, using the AWS, for at least 3 days If the total score reaches 5, monitor hourly & notify the medical officer or drug & alcohol nurse practitioner Depending on the resources of the local area, these may need review As per previous slide in a non ED environment. Ask for any comments or questions.

7: Indications and guidelines: Pharmacological Treatment (1)
From NSW Drug & Alcohol Withdrawal Clinical Practice Guidelines NSW Health 2007 The most commonly prescribed pharmacological treatment for alcohol withdrawal is diazepam because of its cross-tolerance with alcohol & anti-convulsant properties Two types of regimes for specialist residential or inpatient setting Diazepam loading regime Symptom-triggered sedation These next slides regarding the medical / pharmacological management of alcohol withdrawal as noted are from the NSW Health Withdrawal Guidelines. Please encourage participants to read the full text in the guidelines. You may ask why diazepam is the preferred benzodiazepine besides the reasons on the slide. Discuss the benefits of its long half life. This is especially beneficial for the loading regime method. Ask for any comments or questions.

Diazepam loading regime On the development of withdrawal symptoms initiate diazepam loading 20mg initially, increasing to 80mg over 4-6 hours Or until pt is sedated Medial review required if dose exceeds 80mg & more diazepam can be ordered depending on withdrawal condition Go through this regime. State that this method is often used in detoxification services. Once the patient is sedated the long half life of diazepam may last throughout the majority of the withdrawal period (in uncomplicated withdrawal) and there may not be a need for further diazepam. Highlight the need for review after 80mg due to adjust the doses and check for other possible causes. Ask for any comments or questions.

Symptom-triggered sedation Mild withdrawal CIWA-AR <10 & AWS <4 Supportive care, observations 4 hourly If sedation necessary; 5-10mg oral diazepam every 6-8 hours for first 48 hrs This method is more likely to be used in hospital. Go through these guidelines. Ask for any comments or questions.

Symptom-triggered sedation Moderate withdrawal CIWA-AR & AWS <5-14 Medical officer to assess If alcohol withdrawal confirmed: hourly observations; give oral diazepam immediately; repeat 10mg hourly or 10-20mg 2hrly until the pt achieves good symptom control (up to a total dose of 80mg) Repeat medical review after 80mg of diazepam and if pt is not settling, consider olanzepine (zyprexia) 5-10mg This method is also more likely to be use in hospital. Go through these guidelines. Stress the need for medical review after 80mg to review the need for ongoing medication and to check for possible other causes for the symptoms. Ask for any comments or questions.

Symptom-triggered sedation Severe withdrawal CIWA-AR 20+ & AWS 14+ Urgent management. Give a loading dose Review more frequently until score falls A rising score indicates a need for more aggressive management This method is to be used in hospital and would be classified as a medical emergency and transfer to a high dependency / ICU. Go through these guidelines. Stress the importance to look at more detailed information from the Clinical Withdrawal Guidelines as noted. Ask for any comments or questions.

Contraindications to diazepam include: respiratory failure, significant liver impairment, possible head injury or cerebrovascular accident – in these situations, specialist consultation is essential From NSW Drug and Alcohol Withdrawal Clinical Practice Guidelines NSW Health Go through these points. Mention that oxazepam, due to its short half life may be the drug of choice to use in some causes. Ask for any comments or questions.

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