1. Alcohol Withdrawal Syndrome

2. Alcohol Withdrawal Protocol!
Have you heard??
There are new changes
to the
Alcohol Withdrawal Protocol!

3. Review

4. Definition of Alcohol Withdrawal Syndrome
Alcohol Withdrawal Syndrome is characterized by central nervous system hyperactivity that occurs when an alcohol dependent individual abruptly stops or significantly reduces alcohol consumption.
Alcohol Withdrawal Syndrome encompasses symptoms that can range from mild to life threatening delirium!

5. Today, it is estimated that one in four people are classified as “at-risk” drinkers. These individuals meet the criteria for alcohol abuse or dependence.
Many times, a patient is not even aware themselves that they are considered at risk for alcohol abuse or are indeed alcohol dependent!
You, as the healthcare provider, may come in contact with patients who are alcohol dependent without being aware of it when you first care for them!

6. About 50% of alcohol - dependent patients develop clinically relevant symptoms of withdrawal!
If you are not looking for Alcohol withdrawal, the symptoms can easily be overlooked.
Because deaths have occurred in 10% of untreated alcohol withdrawal delirium and in 25% of those patients with medical or coexistent surgical complications, it is imperative to be on the alert for this life-threatening condition!
(Stern: Massachusetts General Hospital

7. The stigma and ignorance about alcoholism unfortunately contribute and affect two major in–patient problems: Under recognition & Inadequate treatment

8. American Society of Addiction Medicine Guidelines for Proper Treatment of Withdrawal
Provide a safe withdrawal from the drug(s) of dependence and enable the patient to become drug free
Provide a withdrawal that’s humane and protects the patient’s dignity
Prepare the patient for ongoing treatment for the dependence

9. Its important to remember ………
If interventions don’t get implemented early on – withdrawal symptoms are more likely to become more severe and may progress to:
Hallucinations
Seizures
Delirium tremens

10. Withdrawal symptoms can also progress and include:
Arrhythmias
Pneumonia
CNS injury
Exacerbation of underlying pancreatitis or hepatitis

11. Remember, every patient will differ as to how much and when they will experience if, any withdrawal symptoms! Our goal is to recognize who is at risk and prevent!

12. Signs and symptoms team members need to be alert and watch for include…….

13. 6-12 hours of stopping or lowering BAC (blood alcohol concentrations)
Mild Symptoms of Alcohol Withdrawal can occur within hours;
6-12 hours of stopping or lowering BAC (blood alcohol concentrations)

14. Mild Symptoms Anxiety Insomnia Vivid dreams Tremors Headache
Diaphoresis
Palpitations
Anorexia
Gastrointestinal upset- Nausea and Vomiting
Hypervigilance

15. More serious symptoms may present anywhere within 12- 96 hours

16. Within 12 to 24 hours, the patient may also experience…
Visual hallucinations
Tactile hallucinations
Auditory hallucinations – although not as likely

17. may develop between 6 and 48 hours
Withdrawal Seizures
may develop between 6 and 48 hours
after the patients last drink of alcohol…
Seizures are the highest safety risk for patients
in alcohol withdrawal because of the:
Risk for aspiration
Oxygen deprivation
Physical injury from thrashing
Once again, those patients who have experienced repeated episodes of alcohol withdrawal increase their risk for withdrawal seizures.
It is important to get treatment early to prevent status epilepticus

18. Within 48 to 96 hours, the patient may experience Alcohol Withdrawal Delirium
Tachycardia
Hypertension
Low-grade fever – below 100.7F
Agitation
Diaphoresis
Fever greater than F is not withdrawal related and must be evaluated for infectious source

19. Your patient is at risk for Alcohol Withdrawal Delirium
if any of these factors are present:
Severe withdrawal symptoms
History of heavy alcohol use (more than five standard drinks a day for men; more than four standard drinks a day for women)
History of alcohol withdrawal delirium or withdrawal seizures which leads to “Kindling phenomena”
Abnormal liver function
Advanced age

20. repeated cycles of intoxication followed by abstinence
“Kindling”
occurs when a patient
has experienced
repeated cycles of intoxication
followed by abstinence

21. The patient’s neurons undergo long term changes,
causing subsequent episodes of
withdrawal to worsen!
The chemical imbalances
become more pronounced
and this patient is more likely to rapidly
experience seizures
in the absence of alcohol.

22. Alcohol Withdrawal Protocol
All patients are considered eligible for the alcohol withdrawal protocol if a history of alcohol withdrawal delirium tremors or a positive alcohol history or symptoms.
The CIWA-Ar protocol is used to assess and treat patients who may be in/at risk for alcohol withdrawal.
Initiation of this protocol is suggested for patients evaluated to be at risk during the hospital stay to avoid the complication of alcohol withdrawal.

23. Initiating the Alcohol Withdrawal Protocol
During the admitting process, each patient will be asked if they have a history of alcohol use and /or a prior history of alcohol withdrawal.
After discussion with the physician about the history, the physician may order the protocol for alcohol withdrawal order set.
The nurse will monitor the patient using the Alcohol (CIWA-Ar Flow sheet).

24. The CIWA-Ar Scale
Utilizing a standardized monitoring tool for alcohol withdrawal is key to:
Preventing excess morbidity and mortality in patients who are at risk for alcohol withdrawal;
Helping clinical personnel recognize the process of withdrawal before it progresses to more advanced stages;
Intervening with appropriate medications to alleviate symptoms of withdrawal.

25. CIWA - Ar tool Uses both nursing observation
(tremor-sweats-agitation-orientation)
and
patient’s reports or answers
(to 6 other questions the nurse will ask patient to elicit patient experiences of the symptoms which include: anxiety, headache fullness in head, nausea and vomiting- tactile disturbances-auditory disturbances-and visual disturbances being evaluated)

26. The CIWA-Ar has well-documented reliability, reproducibility and validity, based on comparison to ratings by expert clinicians.
The CIWA-Ar scale can measure 10 symptoms (maximum possible score 67).
The assessment requires approx. 5 minutes to perform.

27. CIWA-Ar Assessment Parameters

28. Nausea & Vomiting
Ask: Do you feel sick to your stomach? Have you vomited?” Score appropriately:
0 No nausea and no vomiting
1 Mild nausea with no vomiting 2 3
4 Intermittent nausea with dry heaves 5 6
7 constant nausea, frequent dry heaves

29. Paroxysmal Sweats 0 No sweat visible
1 Barely perceptible sweating, palms moist 2 3
4 Beads of sweat obvious on forehead 5 6
7 Drenching sweats

30. Agitation 0 normal activity 1 somewhat more than normal activity 2 3
4 moderately fidgety and restless 5 6
7 paces back and forth during most of the interview, or constantly thrashes about

31. Headache, fullness in head Ask “Does your head feel different
Headache, fullness in head Ask “Does your head feel different? Does it feel like there is a band around your head?” Do not rate for dizziness or lightheadedness.
0 not present
1 very mild
2 mild
3 moderate
4 moderately severe
5 severe
6 very severe
7 extremely severe

32. Anxiety Ask “Do you feel nervous?”
0 no anxiety, at ease
1 mildly anxious 2 3
4 moderately anxious, or guarded, so anxiety is inferred 5 6
7 equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions

33. Tremor Arms extended and fingers spread apart.
No tremor
1 Not visible, but can be felt fingertip to fingertip 2 3
4 Moderate, with patient’s arms extended 5 6
7 Severe, even with arms not extended

34. Visual Disturbances Ask “Does the light appear to be too bright
Visual Disturbances Ask “Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?”
0 not present
1 very mild sensitivity
2 mild sensitivity
3 moderate sensitivity
4 moderately severe hallucinations
5 severe hallucinations
6 extremely severe hallucinations
7 continuous hallucinations

35. Tactile Disturbances Ask “Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?”
0 none
1 very mild itching, pins and needles, burning or numbness
2 mild itching, pins and needles, burning or numbness
3 moderate itching, pins and needles, burning or numbness
4 moderately severe hallucinations
5 severe hallucinations
6 extremely severe hallucinations
7 continuous hallucinations

36. Auditory Disturbances Ask “Are you more aware of sounds around you
Auditory Disturbances Ask “Are you more aware of sounds around you? Are they harsh: Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?”
0 not present
1 very mild harshness or ability to frighten
2 mild harshness or ability to frighten
3 moderate harshness or ability to frighten
4 moderately severe hallucinations
5 severe hallucinations
6 extremely severe hallucinations
7 continuous hallucinations

37. Orientation and clouding of sensorium Ask “What day is this
Orientation and clouding of sensorium Ask “What day is this? Where are you? Who am I?
0 oriented and can do serial additions
1 cannot do serial additions or is uncertain about date
2 disoriented for date by no more than 2 calendar days
3 disoriented for date by more than 2 calendar days
4 disoriented for place and/or person

38. CIWA-Ar Scoring
1. The total of the number of points accrued from these 10 parameters will give you the CIWA-Ar score of your patient.
2. The nurse will score the patient on the flow sheet each time the assessment is completed.
3. Some of the assessment criteria is objective. Two different nurses may scoring the patients at the same time might have slightly different scores. However should not be large discrepancies between the two score.
4. Follow orders per physician in the CIWA-Ar order set.

39. The Alcohol Withdrawal Protocol itself consists of:
Physician orders:
Activity level:
Up to chair and bathroom privileges as tolerated when awake, responsive and stable.
Oxygen per nasal cannula to maintain O2 saturation 93% or greater

40. Physician's Orders: LABORATORY: RUN ALL LABS “STAT”
Magnesium Level (Serum)
Comprehensive Metabolic Panel
Partial thromboplastin time (aPTT ) (blood)
Prothrombin time/international normalized ratio PT/INR) (blood)
CBC
Alcohol (ethanol), quantitative (blood)
Drugs of abuse, qualitative (urine)
Methanol, qualitative, (blood) Ingestion suspected

41. New Scoring Guidelines!
Minimal to Mild Withdrawal: Less than 6 or below
Moderate Withdrawal: 6-15
Severe Withdrawal: 15 or more (impending delirium tremens).

42. Vital Signs and CIWA-A assessment:
Frequency of
Vital Signs and CIWA-A assessment:
If CIWA-A is less than 6, then repeat score and vital signs every 4 hours until less than 6
(x 4 scores, then discontinue protocol)
If CIWA-A score is greater than 6 - Nurse is to perform vitals signs and CIWA-A assessment hourly until score is less than 6.

43. Vital Signs and CIWA-A assessment
Frequency of
Vital Signs and CIWA-A assessment
continued:
If CIWA-A score remains greater than 6 x 72 hours - notify the physician!
If CIWA-A score is greater than or equal to 20, notify physician and obtain order to transfer to ICU if appropriate.

44. CIWA-Ar Algorithm CIWA-Ar SCORE and Vital Signs Frequency
Less than 6
6 or Greater
Greater than 8
Greater than or equal to 20
Repeat CIWA-Ar score and Vital Signs Every 4 Hours until score is less than 6 X 4 scores and then discontinue protocol.
Repeat CIWA- Ar score and Vital Signs Hourly until score is less than 6.
Greater than 8 x 72 hours, notify physician.
Greater than or equal to 20, notify physician and obtain order to transfer to ICU if appropriate.
Call physician if patient has CIWA-Ar score greater than 8x72 hours or greater than or equal to 20.
Or if
Vital Signs: HR>110/min., DBP>120 mmHg, or SBP >180 mmHG

45. Call Physician if patient has:
Heart rate greater than 110
Diastolic Blood Pressure (DBP)
greater than 120mm Hg or
Systolic Blood Pressure (SBP)
greater than 180mm Hg

46. Medication Change
Depending upon the which criteria your patient falls under, the new protocol will use either Diazepam (Valium) or Lorezapam (Ativan)

47. Is there serious liver disease (PT/INR > 13 sec)?
Is there serious pulmonary disease (FEV1 < 1.5 liters)?
Is the patient elderly? NO
YES
Diazepam (Valium) 5mg intravenously,
*reassess CIWA-Ar in 1 hour*
Repeat dose every 1 hour if CIWA-Ar score is above 6
Lorazepam (Ativan) 2mg intravenously,
reassess CIWA-Ar in 1 hour,
Repeat dose every 1 hour if CIWA-Ar is above 6.

48. Medication Changes: Dosing is still based on the CIWA-A score range.
The medication frequency has changed to every 1 hour for CIWA-A score above 6
and vital signs taken every hour until score
is less than 6 .

49. Medications (as found on Physician’s orders)
Discontinue all previous benzodiazepine orders
BENZODIAEPINES:
IF CIWA-Ar score is greater than 6, CHOOSE ONE:
Recommended treatment for withdrawal
for most patients:
Diazepam (Valium) 5mg intravenously,
*reassess CIWA-Ar in 1 hour*
Repeat dose every 1 hour if CIWA-Ar score is above 6

50. For patients with advanced cirrhosis,
INR greater than 1.3 or
age greater that 60;
Choose:
Lorazepam (Ativan) 2mg intravenously,
reassess CIWA-Ar in 1 hour,
Repeat dose every 1 hour if CIWA-Ar is above 6.

51. More than 6 mg Lorezepam (Ativan) Greater than 20 mg Diazepam (Valium)
CALL PHYSCIAN
IF PATIENT REQUIRES:
More than 6 mg Lorezepam (Ativan) or
Greater than 20 mg Diazepam (Valium)
in three hours

52. IV Fluids
Sodium Chloride 0.9%
__________ mL/hr.

53. Nutritional Supplements
Thiamine 100mg , multivitamin 10mL, folic acid 1mg in Sodium Chloride 0.9% 500 mL _________mL/ daily for 3 days. Continue IV route if patient remains NPO.
After 3 days, if patient is eating, change vitamins to:
Thiamine 100mg tablet orally daily
Therapeutic multivitamin with minerals tablet orally daily
Folice acid 1mg tablet orally daily

54. Nursing Responsibilities
First, therapeutic communication is key to taking care of your patient!
Your values and opinions may very well influence how you communicate with your patient and their family.
It is important to convey respect and acceptance
Strive to be non-judgmental and professional at all times

55. Remember alcoholism is a disease.
Alcohol is a common problem in many people’s lives. We need to treat it like we would any other disease.
Educate the patient and the family
** Educate that the absence of alcohol can make them very ill and we want to be able to provide them with the right kind of care that they will need. By knowing how much and how frequently they drink we can prevent severe withdrawal symptoms.
Make sure every patient and family receives the
Lake Health folder entitled “Alcohol Dependence.”

56. Nursing Care includes…….
Providing a quiet and restful environment
Decrease environmental stimuli.
Providing comfort through positioning
(remember a somnolent patient is at risk for aspiration)
Use medications as ordered

57. Foods and fluids – offer regularly to maintain hydration and decrease gastric distress.
Nutrition consult – this patient is a potential risk for malnutrition which will affect healing process and hospitalization stay.
Avoid Foley catheters!

58. Toileting – provide a regular toileting schedule for confused patients
Toileting – provide a regular toileting schedule for confused patients. Offer urinal, bedside commode and be ready to assist patient to the bathroom each time because patient may be medicated and unsteady.
Ambulate frequently to reduce problems with immobility and reduce stress of withdrawal. Some patients may want to pace in a safe area.
Initiate Fall Risk precautions

59. SAFETY
Safety is always a primary concern for all team members involved with providing care for this patient. Guidelines include:
Be aware and alert for signs of withdrawal
Provide sitter as necessary
Don’t wear anything that the patient can grab!

60. SAFETY
Reinforce safe practices with staff including how you position yourself with the patient – do not allow a patient to block your exit
Have another person with you if the patient is agitated when providing care,
Always be alert for escalation in agitation and aggressiveness.