Alcohol withdrawal

and delirium in the

intensive care unit

By Elisea Rizada
Introduction

Besides nicotine, alcohol is the most abused

drug worldwide. About one-fifth of the
patients seen in clinical practice present with
an alcohol use disorder (AUD).
Alcohol use disorders

Alcohol use disorders (AUD) include a wide

range of drinking behaviors from hazardous
use of alcohol to alcohol abuse, harmful
consumption, and alcohol dependence.
Alcohol dependence

Approximately 10% of all hospitalized patients can

be diagnosed as alcohol-dependent.
Patients with alcohol dependence show the
highest risk of all patients with AUD for severe
complications such as delirium, infection, sepsis,
septic shock, postoperative hemorrhage and long-
term cognitive dysfunction
Identification of AUD patients

Screening patients for AUD is the

precondition to taking preventive measures
and improving outcome as well as reducing
the length of hospital stay (LOS).
AUDIT

The Alcohol Use Disorder Identification Test

(AUDIT) developed by the World Health
Organization (WHO) consists of ten questions with
a score ranging from zero to 40 points
An overall score of eight or more points reveals
hazardous or harmful alcohol use (ICD-10)
Criteria for diagnosis of alcohol dependence
AUDIT-Test: Alcohol-Use Disorder Identification Test
Biomarkers

Biomarkers frequently used in clinical practice for

screening alcohol abuse are surrogate markers like
mean corpuscular volume of the red blood cell
(MCV), gamma-glutamyl transpeptidase (GGT)
and carbohydrate deficient transferrin (CDT)
because they only reflect the status of organ
dysfunction of an ongoing disease.
CIWA-Ar Scale
Delirium tremens and alcohol withdrawal
syndrome (AWS) in ICU

The revised Clinical Institute withdrawal

assessment scale (CIWA-Ar) is a commonly
used validated tool to diagnose alcohol
withdrawal. The CIWA-Ar [39] scores from
zero to 67 points to evaluate the severity of
alcohol withdrawal.
Delirium Detection Score (DDS)
Screening and Prevention of Alcohol Withdrawal
Delirium tremens

Delirium triggered by alcohol withdrawal is an

often seen phenomenon in ICU patients. Patients
admitted to the ICU are often not identified as
AUD patients. This means that withdrawal
prophylaxis is not administered.
Perioperative preventive treatment for AUD
Symptom-orientated therapy according to the prevalent symptoms – titrated to the needs of the patient
Prevention of AWS and Delirium

A previous study found that postoperative complications

and ICU length of stay increased in AUD patients when
prophylaxis was not applied.
AWS occurs in 50% of AUD patients when preoperative
diagnosis is missed. It can be reduced by 50% in these
patients if preventive measures are taken.
Therefore, the prevention of alcohol withdrawal syndrome
(AWS) and delirium tremens should start before elective
surgery to reduce health risks
Treatment of AWS-related delirium

An appropriate initial AWS treatment

protocol would include repetitive titration of
5–10 mg of diazepam or 2–4 mg of
lorazepam every 10 min until the aimed
score is achieved and doubling the
administered dose every third time should
the effect not appear to be relevant.
Treatment after ICU stay

Patients with alcohol dependence need ongoing

outpatient care with psychosocial intervention and
potentially medical pharmacological treatment.
Naltrexone, acamprosate, disulfiram, and topiramate are
used for this purpose. However, without combined
behavioural intervention these treatments should not be
administered.
Conclusion

Delirium due to AWS and progressed to delirium tremens is

a potentially life-threatening complication in ICU settings
which may result in extended ICU length of stay and
worsen patients’ outcome significantly.
A prolonged delirium and ICU length of stay often leads
to substantial health impairment for the patient.
References

 Netherlands Journal of Critical Care - M Paupers, A Schiemann, CD Spies

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