Wednesday, January 20, 2010

Standardized Care Protocol for Postoperative Alcohol Withdrawal – an Article Review

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

It has been a while since I’ve had a patient with postoperative alcohol withdrawal.  I can still recall my first exposure to this problem as a 3rd year medical student at the Veteran’s Hospital.  It was my first clinical rotation – surgery service at the VA.
Browsing the CME articles on the JAMA website, I came across the article (full reference below):  Improved Outcomes in Patients With Head and Neck Cancer Using a Standardized Care Protocol for Postoperative Alcohol Withdrawal.  For me it was a nice review of the problem with updates on current drug use/protocol.
Their protocol is based on three distinct clusters of symptoms characterize alcohol withdrawal syndrome (AWS).
Type A symptoms represent central nervous system (CNS) excitation and include anxiety, dysphoria, enhanced reaction to abrupt stimuli, insomnia, mood lability, motor activity, and a sense of foreboding.  Central nervous system excitation usually occurs within 12 to 48 hours after the last drink.
Type B symptoms relate to adrenergic hyperactivity, which manifest as fever, chills, diaphoresis, hypertension, tachycardia, tremors, piloerection, mydriasis, nausea, and palpitations.  Autonomic hyperactivity usually peaks between 24 and 48 hours after cessation of alcohol consumption.
Type C symptoms include attention deficit, disorientation, hyper-alertness, short-term memory impairment, impaired reasoning, psychomotor agitation, and hallucinations signifying delirium. These symptom types may occur alone or in combination.   Delirium typically occurs later, with a variable time course.
The older term delirium tremens may be used in this context to describe the combined symptoms of confusion (type C), hyperadrenergic state (type B), and CNS excitation (type A)

The authors present their experience from March 2003 until March 2005 with 26 consecutive patients prospectively treated for AWS using a standardized care protocol from among 652 patients admitted for head and neck surgical procedures (see the two images below—credit) and compared them with a retrospective comparison group of 14 patients who met the inclusion criteria but were treated from March 2000 to December 2002, prior to the use of the AWS protocol.
Outcomes (preprotocol/protocol)
Transfers from the regular inpatient unit to the ICU for AWS-related cause  -- 29%  vs 4%.
Respiratory arrest -- 14%  vs 4%.
Mechanical restraints used  -- 57% vs 42% .
Delirium present --  79% vs 29%.  When present, delirium lasted a mean (SD) of 3.2 days in the preprotocol group and 3.3  days in the protocol group.
Violence (such as biting, scratching, kicking, verbal outbursts, and other violent manifestations) present  -- 36% vs 8%.
One or more wound complications present -- 50% vs 46%. 
No seizures, falls, or deaths occurred in either cohort during the inpatient stay. No patient developed delirium tremens.

The article  is worth the review even with the small number of subjects.

Improved Outcomes in Patients With Head and Neck Cancer Using a Standardized Care Protocol for Postoperative Alcohol Withdrawal; Arch Otolaryngol Head Neck Surg. 2008;134(8):865-872; Christopher D. Lansford, MD; Cathleen H. Guerriero, RN, BSN; Mary J. Kocan, MSN; Richard Turley, MD; Michael W. Groves, MD; Vinita Bahl, DMD, MPP; Paul Abrahamse, MA; Carol R. Bradford, MD; Douglas B. Chepeha, MD; Jeffrey Moyer, MD; Mark E. Prince, MD; Gregory T. Wolf, MD; Michelle L. Aebersold, RN; Theodoros N. Teknos, MD

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