Practice Patterns in the Diagnosis and Management of Alcohol Withdrawal Syndrome in Indian Intensive Care Units
Justin Aryabhat Gopaldas, Mahesha Padyana, Poonam P Rai
Alcohol use disorders, Alcohol withdrawal syndrome, Benzodiazepines, Delirium tremens, Pneumonia, Prediction of Alcohol Withdrawal Severity Scale, Thiamine in alcohol withdrawal syndrome, Urinary tract infection, Wernicke's encephalopathy
Citation Information :
Gopaldas JA, Padyana M, Rai PP. Practice Patterns in the Diagnosis and Management of Alcohol Withdrawal Syndrome in Indian Intensive Care Units. Indian J Crit Care Med 2023; 27 (11):816-820.
Alcohol use disorders (AUDs) are prevalent in intensive care units (ICUs). Alcohol abuse and/or dependence, leading to alcohol withdrawal syndrome (AWS), is as high as 10% or more. There seem to be wide variations in management strategies used to manage these patients, prompting an evaluation of the knowledge gap as well as finding the barriers. Noting lack of such literature in the Indian setting, a survey is undertaken to evaluate practice patterns surrounding the identification and management of alcohol dependence/abuse and AWS in the Indian critical care scenario.
The main respondents of the survey are independent practitioners with anesthesia as their base specialty and overwhelmingly practice in multidisciplinary ICUs. They estimated AUD prevalence to be under 10%. The reason most expressed for lack of AUD documentation is fear of insurance rejection.
Very few used risk assessment tool in evaluation of AUDs and AWS. Awareness of ICD 10/DSM-V components of AWS diagnosis was negligible. Chlordiazepoxide and lorazepam were used either in a fixed- or symptom-based therapy. Compared to available literature, haloperidol use is excessive, while barbiturates rarely. The wide variation is seen with the dose and frequency of thiamine in AWS without neurological complications. The impact on mortality and morbidity is poorly understood.
In conclusion, the survey reported a lower prevalence compared to international literature. Insurance rejection is one of the main factors in limiting adequate history taking or documenting AUDs. Alcohol withdrawal syndrome risk assessment, monitoring, and management is variable and suboptimal. Variability in all aspects of AUDs is attributable to the knowledge gap. Further studies are needed to bridge the research gap.
Murthy P, Manjunatha N, Subodh BN, Chand PK, Benegal V. Substance use and addiction research in India. Indian J Psychiatry 2010;52 (Suppl 1):S189–S199. DOI: 10.4103/0019-5545.69232.
Cervellione KL, Shah A, Patel MC, Curiel Duran L, Ullah T, Thurm C. Alcohol and drug abuse resource utilization in the ICU. Subst Abuse 2019;13:1178221819869327. DOI: 10.1177/1178221819869327.
Secombe PJ, Stewart PC. The impact of alcohol-related admissions on resource use in critically ill patients from 2009 to 2015: An observational study. Anaesth Intensive Care 2018;46(1):58–66. DOI: 10.1177/0310057X1804600109.
Dixit D, Endicott J, Burry L, Ramos L, Yeung SYA, Devabhaktuni S, et al. Management of acute alcohol withdrawal syndrome in critically ill patients. Pharmacotherapy 2016;36(7):797–822. DOI: 10.1002/phar.1770.
Spies CD, Otter HE, Hüske B, Sinha P, Neumann T, Rettig J, et al. Alcohol withdrawal severity is decreased by symptom-orientated adjusted bolus therapy in the ICU. Intensive Care Med 2003;29:2230–2238. DOI: 10.1007/s00134-003-2033-3.
Awissi DK, Lebrun G, Coursin DB, Riker RR, Skrobik Y. Alcohol withdrawal and delirium tremens in the critically ill: A systematic review and commentary. Intensive Care Med 2013;39(1):16–30. DOI: 10.1007/s00134-012-2758-y.
Gupta NM, Lindenauer PK, Yu PC, Imrey PB, Haessler S, Deshpande A, et al. Association between alcohol use disorders and outcomes of patients hospitalised with community-acquired pneumonia. JAMA Network Open 2019;2(6):e195172. DOI: 10.1001/jamanetworkopen.2019.5172.
Sutton LJ, Jutel A. Alcohol withdrawal syndrome in critically ill patients: Identification, assessment, and management. Crit Care Nurse 2016;36(1):28–38. DOI: 10.4037/ccn2016420.
Mackinnon N, Bhatia U, Nadkarni A. The onset and progression of alcohol use disorders: A qualitative study from Goa, India. J Ethn Subst Abuse 2019;18(1):89–102. DOI: 10.1080/15332640.2017.1326863.
Sarff M, Gold JA. Alcohol withdrawal syndromes in the intensive care unit. Crit Care Medicine 2010;38(9 Suppl):S494–S501. DOI: 10.1097/ccm.0b013e3181ec5412.
Agrawal V, Garimella PS, Roshan SJ, Ghosh AK. Questionnaire survey of physicians: Design and practical use in nephrology. Indian J Nephrol 2009;19(2):41–47. DOI: 10.4103/0971-4065.53320.
Silber JH, Rosenbaum PR, Niknam BA, Ross RN, Reiter JG, Hill AS, et al. Comparing outcomes and costs of medical patients treated at major teaching and non-teaching hospitals: A national matched analysis. J Gen Intern Med 2020;35(3):743–752. DOI: 10.1007/s11606-019-05449-x.
Mirijello A, D'Angelo C, Ferrulli A, Vassallo G, Antonelli M, Caputo F, et al. Identification and management of alcohol withdrawal syndrome. Drugs 2015;75(4):353–365. DOI: 10.1007/s40265-015-0358-1.
Williamson L. Destigmatizing alcohol dependence: The requirement for an ethical (not only medical) remedy. Am J Public Health 2012;102(5):e5–e8. DOI: 10.2105/AJPH.2011.300629.
Duby JJ, Berry AJ, Ghayyem P, Wilson MD, Cocanour CS. Alcohol withdrawal syndrome in critically ill patients: protocolized versus nonprotocolized management. J Trauma Acute Care Surg 2014;77(6):938–943. DOI: 10.1097/TA.0000000000000352.
Jesse S, Bråthen G, Ferrara M, Keindl M, Ben-Menachem E, Tanasescu R, et al. Alcohol withdrawal syndrome: Mechanisms, manifestations, and management. Acta Neurol Scand 2017;135(1):4–16. DOI: 10.1111/ane.12671.
Mainerova B, Prasko J, Latalova K, Axmann K, Cerna M, Horacek R, et al. Alcohol withdrawal delirium diagnosis, course and treatment. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2015;159(1):44–52. DOI: 10.5507/bp.2013.089.
Amato L, Minozzi S, Vecchi S, Davoli M. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev 2010;(3):CD005063. DOI: 10.1002/14651858.CD005063.pub3.
Jan MM, Majeed N, Mufti S, Margoob MA. Management of patients with alcohol withdrawal syndrome. Int J Indian Psychol 2020;8(1):1074–1089. DOI: 10.25215/0801.135.
Sachdeva A, Chandra M, Deshpande SN. A Comparative study of fixed tapering dose regimen versus symptom-triggered regimen of lorazepam for alcohol detoxification. Alcohol Alcohol 2014;49(3):287–291. DOI: 10.1093/alcalc/agt181.
Wong A, Benedict NJ, Lohr BR, Pizon AF, Kane-Gill SL. Management of benzodiazepine-resistant alcohol withdrawal across a healthcare system: Benzodiazepine dose-escalation with or without propofol. Drug Alcohol Depend 2015;154:296–299. DOI: 10.1016/j.drugalcdep.2015.07.005.
Darrel Hughes. Benzodiazepine-refractory alcohol withdrawal. REBEL EM blog, April 28, 2016 (Last accessed 24.03.2021).
Latt N and Dore G. Thiamine in Wernicke's encephalopathy. Intern Med J 2014;44(9):911–915. DOI: 10.1111/imj.12522.
Ambrose ML, Bowden SC, Whelan G. Thiamin treatment and working memory function of alcohol-dependent people: Preliminary findings. Alcohol: Clin Exp Res 2001;25(1):112–116. DOI: 10.1111/j.1530-0277.2001.tb02134.x.
Smith H, McCoy M, Varughese K, Reinert JP. Thiamine dosing for the treatment of alcohol-induced Wernicke's encephalopathy: A review of the literature. J Pharm Technol 2021;37(2):107–113. DOI: 10.1177/8755122520962859.
Ganatra RB, Breu AC, Ronan MV. Which patients hospitalized with alcohol withdrawal syndrome should receive high-dose parenteral thiamine? Cleve Clin J Med 2023;90(1):22–25. DOI: 10.3949/ccjm.90a.22026.
Praharaj SK, Munoli RN, Shenoy S, Udupa ST, Thomas LS. High-dose thiamine strategy in Wernicke–Korsakoff syndrome and related thiamine deficiency conditions associated with alcohol use disorder. Indian J Psychiatry 2021;63(2):121–126. DOI: 10.4103/psychiatry.IndianJPsychiatry_440_20.
Thomson AD, Cook CCH, Touquet R, Henry JA. The Royal College of Physicians report on alcohol: Guidelines for managing Wernicke's encephalopathy in the Accident and emergency department. Alcohol Alcohol 2002;37(6):513–521. DOI: 10.1093/alcalc/37.6.513.