Marino The ICU Book 4e, IE

805

Disorders of Consciousness

Table 44.2

Clinical Features of Alcohol Withdrawal

Features

Onset after Last Drink

Duration

Early Withdrawal

6–8 hours

1–2 days

Anxiety Tremulousness Nausea

Generalized Seizures

6–48 hours

2–3 days

Hallucinations

12–48 hours

1–2 days

Visual Auditory Tactile

Delirium Tremens

48–96 hours

1–5 days

Fever Tachycardia Hypertension

Agitation Delirium

Adapted from Reference 17.

Treatment The drugs of choice for treating alcohol withdrawal delirium are the ben- zodiazepines (19), which mimic the CNS depressant effects of alcohol by stimulating GABA receptors in the brain. An added benefit of benzodi- azepines is protection against generalized seizures. ICU REGIMEN: For patients who require care in the ICU, intravenous lorazepam is an appropriate choice for the management of DTs (19). For initial control, give 2 – 4 mg IV every 5 – 10 minutes until the patient is calm. Thereafter, administer IV lorazepam every 1 – 2 hours in a dose that maintains calm (a dose of 2 – 4 mg should be sufficient in most cases). After at least 24 hours of calm, the dose can be tapered to determine if the delirium persists. It is important to taper benzodiazepines as soon as pos- sible because they accumulate and can produce prolonged sedation and a prolonged ICU stay. An additional concern with prolonged administra- tion of IV lorazepam is propylene glycol toxicity (see page 605). For more information on benzodiazepines, see Chapter 51. THIAMINE: The clinical manifestations of DTs can mask an acute Wernicke’s encephalopathy that is precipitated by glucose infusions in IV fluids, as described earlier. Therefore, thiamine supplementation is a stan- dard practice during the treatment of DTs. The popular dose is 100 mg daily, which can be given intravenously without harm.