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Subsections
Alcohol Abuse: Withdrawal

Alcohol Abuse

Alcohol Abuse: Withdrawal

See Also: Toxicology: Alcohol Withdrawal

Background

  1. Alcohol withdrawal is a life-threatening condition
  2. 500,000 cases of withdrawal are severe enough to require medical therapy each year

Pathophysiology

  1. Withdrawal seen after long periods of sustained high blood-alcohol levels
  2. Periods and levels causing withdrawal can vary greatly between patients
  3. Alcohol CNS depression; abrupt decrease of alcohol unmasking of compensatory overactivity in CNS withdrawal symptoms
  4. Important neurotransmitters involved in withdrawal
    • GABA (gamma-aminobutyric acid)
      • Inhibitory neurotransmitter
      • Downregulation in withdrawal hyperarousal
    • Norepinephrine
      • Elevated levels found in CSF of patients undergoing withdrawal
    • Serotonin
      • Involved in tolerance and craving for alcohol
  5. Seizures
    • Usually occur within 48 hrs of last drink
      • Most often seen in patients with long history of heavy alcohol use
      • Can occur as early as 2 hrs after last drink
      • 3% of alcoholics have seizures
        • 3% of those develop status epilepticus
  6. Hallucinations
    • Specific hallucinations occurring within 12-24 hrs of abstinence and resolving with 24-48 hrs
    • Not related to delirium tremens
  7. Delirium tremens (DT)
    • Serious medical emergency
      • Mortality rate up to 5%
    • Onset usually 48-96 hr after last drink, and can last for 1-5 days
    • Syndrome consists of
      • Tachycardia, hypertension, vomiting, diaphoresis
      • Hallucinations, disorientation, agitation, global clouding of consciousness
      • Low-grade fever, agitation, dehydration
    • Risk factors for developing DT
      • History of sustained drinking
      • History of previous DT
      • Age > 30 yo
      • Concurrent illness

Treatment

  1. Important to exclude other illnesses (eg, infection, trauma, drug overdose, metabolic abnormalities, liver failure, GI bleeding)
    • Conditions may be coexisting with withdrawal
    • Must treat coexisting conditions as well as withdrawal
  2. Treatment of withdrawal consists of alleviating symptoms, and correcting metabolic abnormalities and comorbid conditions
  3. Patients should be placed in quiet, protected space
    • Restraints if combative or suffering from DT
  4. Isotonic IV fluids until patient is euvolemic
    • Thiamine 100 mg IV or IM to decrease risk of encephalopathy
    • Multivitamins in IV fluid
    • Correct electrolyte abnormalities
    • Severe cases may require blood gas monitoring/central monitoring
  5. Drug therapy
    • Benzodiazepines
      • Mainstay of treatment of withdrawal symptoms
      • Prevent progression of minor withdrawal symptoms to major, reduce agitation
      • Long-acting agents preferred
      • Diazepam, chlordiazepoxide and lorazepam most commonly used
      • May be give PO, IV, IM
        • Route of administration depends on clinical setting
      • Dosing dependent upon clinical setting, severity of withdrawal symptoms, comorbid conditions
      • Most favor fixed dosing schedule vs. symptom triggered schedule
    • Barbiturates
      • Used for patient’s refractory to benzodiazepines
      • Phenobarbital, propofol
    • Other drugs
      • Baclofen: GABA-beta receptor agonist; can lower seizure threshold, off-label use not recommended
      • Anticonvulsants
        • Phenytoin useful for status epilepticus
        • Carbamazepine contraindicated
      • Antipsychotics
        • Lower seizure threshold, contraindicated
      • Centrally acting alpha-2 agonists, beta-blockers
        • Not useful
  6. Consider ICU admission if
    • Age > 40 yo
    • Cardiac disease, hemodynamic instability, severe acid-base abnormality
    • Severe electrolyte abnormalities, renal insufficiency
    • Respiratory insufficiency, serious infection, GI bleeding
    • Hyperthermia, rhabdomyolysis
    • History of prior alcohol withdrawal with DT, need for high dose of sedatives to control symptoms
  7. See also treatment of alcohol dependency and EtOH withdrawal
Nursing Considerations

  1. Assessment
    • Thorough H&P to include
      • History of
        • Alcohol or other substance use/ abuse
        • Types of substances
        • Amount used, route(s)
        • Most recent use
        • Previous withdrawal and withdrawal symptoms if applicable
      • Inquire about adverse consequences of use/abuse
        • Family relationships
        • Financial
        • Social
        • Employment
        • Legal
      • Assess family support and facilitate resources for significant others
      • Assess patient/ family knowledge of effects of abuse/ dependence: behavioral, physical and psychological
    • PE
      • VS: RR, HR, BP, pulse, temp
      • Assess pupils for dilation
      • S/S to inquire about
        • Itching
        • Pins & needles feeling
      • Identify any pre-existing or contributing illnesses
      • Know S/S of alcohol withdrawal
        • Mild to moderate psychological symptoms
          • Feeling of jumpiness or nervousness
          • Feeling of shakiness
          • Anxiety
          • Irritability or easily excited
          • Emotional volatility, rapid emotional changes
          • Depression
          • Fatigue
          • Difficulty with thinking clearly
          • Bad dreams
        • Mild to moderate physical symptoms
          • Headache general, pulsating
          • Sweating of palms of hands or face
          • N/V
          • Loss of appetite
          • Insomnia
          • Paleness
          • Palpitations
          • Eyes, pupils different size (enlarged, dilated pupils)
          • Skin, clammy
          • Abnormal movements
          • Tremor of hands
          • Involuntary, abnormal movements of eyelids
        • Severe symptoms
          • State of confusion and hallucinations (visual) known as delirium tremens
          • Agitation
          • Fever
          • Convulsions
          • Blackouts
      • Delirium tremens (DT) can occur 2-5 days after last drink
        • Patients should be placed in quiet, protected space
        • DT is a medical emergency and should be treated on an inpatient basis, often in an ICU setting
    • Labs as ordered, monitor for electrolyte imbalance
      • Electrolytes
      • Glucose
      • LFTs
      • Serum alcohol level
  2. Diagnosis: Nursing Dx
    • Deficient knowledge r/t disease process and treatment plan
    • Noncompliance with treatment program
    • Anxiety
    • Fear
    • Confusion
    • Nausea
    • Ineffective coping
    • Insomnia
    • Risk for deficient fluid volume
    • Ineffective health maintenance
    • Interrupted family processes or dysfunctional family process
    • Caregiver role strain
    • Risk for self and/or other directed violence
  3. Outcome Identification
    • Patient successfully withdrawals from alcohol
    • Patient understands disease and treatment process
    • Patient compliant with lifestyle change and treatment plan
  4. Plan
    • Medically assisted detoxification
    • Monitor, treat and support S/S of withdrawal
    • Referral to outpatient program for continued recovery
    • Patient education
  5. Implement
    • Monitor patient for DT "shakes" approx 12-24 hrs after last drink
      • DT is a medical emergency
    • Tremor may be accompanied by
      • Tachycardia
      • Diaphoresis
      • Anorexia
      • Insomnia
    • Administration of meds to control withdrawal symptoms is specific to severity of symptoms, clinical setting, comorbid conditions, additional substances consumed
      • Monitor for signs of overmedication
    • Fluids to prevent dehydration and electrolyte imbalance, either PO or IV as indicated
    • Attention to patient safety
      • Restraints if necessary and/or 1:1 observation may be necessary
    • Frequent monitoring of patient's VS, q 30 minutes
      • BP
      • HR
      • RR
      • Temp
      • Pulse
    • Follow-up labs as required/ordered
    • After 24-72 hrs, patient may have generalized seizures
    • Patient with alcohol addiction may require vitamin supplementation with
      • Thiamine
      • Folic acid
      • Multivitamin
    • Encourage participation in a substance abuse program
      • Offer support groups like Alcoholics Anonymous
        • Meeting times and locations, can be found at www.aa.org
    • Patient education
      • Teach patient/ family health risks of alcohol abuse
        • Liver disease
        • Pancreatic disease
        • Hypertension
        • Stroke
      • Instruct patients that are mildly dependent on importance of proper diet which will prevent most of mild withdrawal symptoms from occurring
  6. Evaluation
    • Patient successfully withdrawals from alcohol
    • Adverse symptoms of alcohol withdrawal are no longer present
    • Patient/family are compliant with treatment plan and lifestyle modifications
    • Patient/family acknowledge alcoholism is a disease and its negative effects

Nursing Considerations References

  1. Hinkle JL, Cheever KH. Brunner & Suddarth's Textbook of Medical-Surgical Nursing. 13th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.
  2. Gulanick M, Myers, J. Nursing Care Plans: Diagnoses, Interventions, and Outcomes. 7th ed.St. Louis, MO: Elsevier Mosby; 2011.
  3. Ycaza-Gutierrez MC, Wilson L, Altman M. Bedside Nurse-Driven Protocol for Management of Alcohol/Polysubstance Abuse Withdrawal. Crit Care Nurse. 2015;35(6):73-76.
  4. Birch Hurst G. Caring for patients in alcohol withdrawal. American Nurse Today. June 2012 Vol. 7 No. 6. Available at http://www.americannursetoday.com/caring-for-patients-in-alcohol-withdrawal/. Accessed December 2015.
  5. Carpenito-Moyet L. Nursing Care Plans & Documentation: Nursing Diagnoses and Collaborative Problems. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins;2009. p 441-

Contributors

Nursing Considerations Updated/Reviewed: December 2015