Alcoholism is prevalent in up to 20% of inpatient adults,(1) presenting a significant challenge when providing nursing care for the critically ill patient who develops acute alcohol withdrawal syndrome (AWS). Many of these patients are already compromised by underlying medical conditions, so alcohol withdrawal symptoms often complicate the clinical picture. These symptoms, which can be seen as early as 6 to 12 hours after the patient’s last drink, can range from mild to severe, can be mistaken for other serious medical conditions – such as stroke, sepsis, hypoglycemia and hypoxia – and can increase the associated risk of morbidity and mortality.(2)
If left untreated, mortality rates from severe alcohol withdrawal and delirium tremens (DTs) have been shown to be as high as 20%.(3) If AWS is recognized early and improved treatment is instituted, mortality rates have been reduced to 1% to 5%.(3) Nurses and other care providers must be able to recognize early and severe signs of AWS. They must quickly and efficiently assess the patient and initiate proper treatment, while instituting supportive care beyond medications and monitoring.
Clinical Features of AWS
The patient experiencing AWS can manifest a wide range of signs and symptoms.(4) Mild withdrawal symptoms can include insomnia, anxiety, nausea and vomiting, hyperreflexia, diaphoresis and mild autonomic hyperactivity. More moderate symptoms are intense anxiety, tremors and excessive adrenergic symptoms. Severe symptoms are characterized by alterations of sensorium, such as disorientation, agitation and hallucinations, along with severe autonomic hyperactivity, such as tachycardia, hypertension, seizures, tachypnea, hyperthermia, diaphoresis, and DTs.(3) Typically, the latter begin within 48 to 96 hours of the patient’s last drink and can last up to a week. DTs or seizures have been
shown to develop in up to 20% of inpatients experiencing AWS if not treated promptly and adequately.(4)
Many of the presenting signs and symptoms of AWS are nonspecific and can be confused with other clinical problems, such as electrolyte imbalances, pain and infections. The nurse must understand these symptoms usually manifest within 24 hours of the patient’s last drink, peak in two to seven hours, and terminate in two to seven days.
Clinical Assessment for AWS
Consistent and precise patient assessment is necessary to identify AWS. Different assessment tools have been used over the years, but the 10-item revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) is the most common tool for initial assessment and ongoing monitoring within the intensive care unit (ICU).(6) Although creating the perfect tool for the critical care setting has been difficult, this scale has been widely used and examined for validity and reliability. In recent years, the CIWA-Ar score has been used in individualized, symptomtriggered therapy (STT) to determine the need and dosing for recommended first-line medication in the prevention and treatment of AWS.(7) The CIWA-Ar also provides an appropriate scale to discern therapy effectiveness and evaluation of severity of withdrawal.
It is recommended that providers focus on reviewing and obtaining a clear picture of the patient’s drug and alcohol usage. Other common causes for changes in mental status should be ruled out; this includes checking the blood gas for early hypoxemia, ordering a glucose and electrolyte laboratory panel, reviewing medications for possible reaction, and assessing for infection and worsening medical or surgical conditions.
Adequate pain management and sleep deprivation must also be considered.
If the patient is intubated or unresponsive, the Riker Sedation-Agitation Scale is often used to assess agitation and sedation. This scale allows monitoring of both under- and over-sedation. It is not designed to detect the onset of AWS.(8)
Nursing Implications and Supportive Care
Nurses should consider patient safety and injury prevention to be major priorities in managing AWS. Uncontrolled behavior can present a threat to the patient and others. The possible hypermetabolic changes put an added burden on a compromised medical condition. A psychiatric consult should be initiated at the first signs of AWS.
Family. If the patient consents, the medical team should talk with the family and determine relationship dynamics. Anger issues and denial may add to the already stressful situation of having a family member in the critical care setting. Alcohol withdrawal behaviors, such as verbal abuse, violent outbursts, and somatic or tactile delusions (e.g., the patient may thrash around and try to hit and remove imagined insects), often can be difficult for family members to observe, making them apologetic or embarrassed, while they personally internalize abusive statements made by the patient. A complete care plan should involve family members. The care team and family must come together in a therapeutic alliance to provide optimal symptom relief and formulate acceptable behavior objectives for the patient. The family should be provided with educational information that defines AWS and outlines symptoms which may occur. They must be cautioned not to internalize abusive statements and to be empathetic and nonjudgmental during this time. Nurses can educate the family about the treatment plan, which could include medications and physical restraints, although restraints will only be used if all other therapeutic measures fail and the patient is a threat to him- or herself or others. Family members should be reassured that the staff understands AWS and will provide compassionate and ojective care. The patient must be managed at each stage of the delusional process and alcohol withdrawal timeframe. Directly confronting the delusional behavior may antagonize the patient and hinder cooperation.(9)
Environment. The patient’s room should be kept quiet and television use prohibited. Relaxing music familiar to the patient may be played quietly in the background. Everyone should move around quietly. The nurse should give simple explanations for care. Persons at the bedside should be calm and patient. Interaction should be minimal and questions limited. If the patient’s behavior becomes unacceptable or aggressive, visitors should quietly withdraw from the room. The patient should be monitored for any facial signs or body language suggestive of aggression.
Using a sitter is controversial in the ICU setting. Observational experience has shown that although an experienced, well-trained nursing assistant can often keep the patient relaxed and compliant with treatment, an inexperienced or temperamentally unsuitable sitter can increase patient anxiety and agitation. Sitters add a significant hospital cost while supporting research on sitter training and usage criteria are lacking.(10)
Restraints. The critically ill patient experiencing moderate to severe AWS symptoms may require both chemical and physical restraints to avoid injury. Benzodiazepines (midazolam and lorazepam), which can cause severe somnolence, hypotension and respiratory depression, are the most commonly used drugs in AWS. The patient should be appropriately monitored and emergency airway equipment kept at the bedside. Low-dose oral benzodiazepines are preferred if the patient is in no immediate danger and cooperative. For those who require intravenous (IV) or intramuscular benzodiazepines, the fastest onset is obtained with IV midazolam (two to three minutes) versus lorazepam (one to five minutes).(11) The goal of the chemical restraint is to control agitation and the patient’s immediate threat behavior to himself and others.
If physical restraints must be used, a written assessment and order are needed to initiate the protocol. The patient’s skin should be assessed hourly, placing appropriate padding, such as cotton cast dressing, under the restraints with attention to key repetitive rub pressure areas, such as elbows, heels and sacral areas. Siderails should be padded as needed. The patient should be turned at least every two hours as tolerated, skin assessed, and appropriate documentation done.
Nutritional Needs. The patient with chronic alcoholism may be malnourished, causing folate, thiamine, or vitamin B12 deficiency,(12) and is at risk for liver problems and pancreatitis. A baseline prealbumin should be obtained and followed weekly. If the patient is unable to eat and is moderately to severely malnourished, tube feedings or total parenteral nutrition (TPN) should be initiated early. These patients routinely are placed on at least three days of thiamine (100 mg), folate (1 mg), and multivitamins. If a feeding catheter is used, it is taped at the nose and cheek area, with the tubing running toward the head and behind the bed, so minimizing the tubing being within the patient’s reach.
Follow-Up. Once the patient’s medical condition stabilizes, the team should meet to discuss further interventions. A psychiatric team should outline available in-hospital resources and continue to provide support. The alcoholism should be addressed with the patient; it should not be trivialized. The patient needs to clearly understand the impact of AWS on his or her physical and mental health during the hospitalization. Treatment options should be offered at this time.
Because alcoholism is prevalent in adult inpatients, AWS can be a significant challenge for those who provide critical care. If left untreated, severe alcohol withdrawal and DTs can lead to high mortality rates. Nurses and care providers must be able to recognize and assess AWS quickly and efficiently and initiate proper treatment. Appropriate nursing and supportive care beyond medication and monitoring may help decrease morbidity and mortality rates.
4. Riddle E, Bush J, Tittle M, Dilkhush D. Alcohol withdrawal: development of a standing order set. Crit Care Nurse. 2010; 30:38-47.
5. McKinley MG. Alcohol withdrawal syndrome overlooked and mismanaged? Crit Care Nurse. 2005; 25:40-48.
6. Sullivan J, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict. 1989; 84:1353-1357.
7. Hecksel K, Bostwick JM, Jaeger TM, Cha SS. Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general hospital. Mayo Clin Proc. 2008; 83:274-279.
8. Weinberg J, Magnotti L, Fischer PE, et al. Comparison of intravenous ethanol versus diazepam for alcohol withdrawal prophylaxis in the trauma ICU: results of a randomized trial. J Trauma. 2008; 64:99-104.
10. Rausch D, Bjorklund P. Decreasing the costs of constant observation. J Nurs Adm. 2010; 40:75-81.
The authors have no disclosures to report.