A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens

Jeffrey (Jeff) Gold, Binaya Rimal, Anna Nolan, Lewis S. Nelson

Research output: Contribution to journalArticle

104 Citations (Scopus)

Abstract

OBJECTIVE: Patients with severe alcohol withdrawal and delirium tremens are frequently resistant to standard doses of benzodiazepines. Case reports suggest that these patients have a high incidence of requiring intensive care and many require mechanical ventilation. However, few data exist on treatment strategies and outcomes for these subjects in the medical intensive care unit (ICU). Our goal was a) to describe the outcomes of patients admitted to the medical ICU solely for treatment of severe alcohol withdrawal and b) to determine whether a strategy of escalating doses of benzodiazepines in combination with phenobarbital would improve outcomes. DESIGN: Retrospective cohort study. SETTING: Inner-city municipal hospital. PATIENTS: Subjects admitted to the medical ICU solely for the treatment of severe alcohol withdrawal. INTERVENTIONS: Institution of guidelines emphasizing escalating doses of diazepam in combination with phenobarbital. MEASUREMENTS AND MAIN RESULTS: Preguideline (n = 54) all subjects were treated with intermittent boluses of diazepam with an average total and maximal individual dose of 248 mg and 32 mg, respectively; 17% were treated with phenobarbital. Forty-seven percent required intubation due to inability to achieve adequate sedation and need for constant infusion of sedative-hypnotics. Intubated subjects had longer length of stay (5.6 vs. 3.4 days; p = .09) and higher incidence of nosocomial pneumonia (42 vs. 21% p = .08). Postguideline (n = 41) there were increases in maximum individual dose of diazepam (32 vs. 86 mg; p = .001), total amount of diazepam (248 vs. 562 mg; p = .001), and phenobarbital use (17 vs. 58%; p = .01). This was associated with a reduction in the need for mechanical ventilation (47 vs. 22%; p = .008), with trends toward reductions in ICU length of stay and nosocomial pneumonia. CONCLUSIONS: Patients admitted to a medical ICU solely for treatment of severe alcohol withdrawal have a high incidence of requiring mechanical ventilation. Guidelines emphasizing escalating bolus doses of diazepam, and barbiturates if necessary, significantly reduced the need for mechanical ventilation and showed trends toward reductions in ICU length of stay and nosocomial infections.

Original languageEnglish (US)
Pages (from-to)724-730
Number of pages7
JournalCritical Care Medicine
Volume35
Issue number3
DOIs
StatePublished - Mar 2007

Fingerprint

Alcohol Withdrawal Delirium
Phenobarbital
Benzodiazepines
Artificial Respiration
Intensive Care Units
Diazepam
Length of Stay
Alcohols
Incidence
Pneumonia
Guidelines
Municipal Hospitals
Barbiturates
Urban Hospitals
Critical Care
Cross Infection
Hypnotics and Sedatives
Intubation
Cohort Studies
Therapeutics

Keywords

  • Alcohol withdrawal
  • Benzodiazepines
  • Intensive care unit
  • Phenobarbital

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

Cite this

A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens. / Gold, Jeffrey (Jeff); Rimal, Binaya; Nolan, Anna; Nelson, Lewis S.

In: Critical Care Medicine, Vol. 35, No. 3, 03.2007, p. 724-730.

Research output: Contribution to journalArticle

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abstract = "OBJECTIVE: Patients with severe alcohol withdrawal and delirium tremens are frequently resistant to standard doses of benzodiazepines. Case reports suggest that these patients have a high incidence of requiring intensive care and many require mechanical ventilation. However, few data exist on treatment strategies and outcomes for these subjects in the medical intensive care unit (ICU). Our goal was a) to describe the outcomes of patients admitted to the medical ICU solely for treatment of severe alcohol withdrawal and b) to determine whether a strategy of escalating doses of benzodiazepines in combination with phenobarbital would improve outcomes. DESIGN: Retrospective cohort study. SETTING: Inner-city municipal hospital. PATIENTS: Subjects admitted to the medical ICU solely for the treatment of severe alcohol withdrawal. INTERVENTIONS: Institution of guidelines emphasizing escalating doses of diazepam in combination with phenobarbital. MEASUREMENTS AND MAIN RESULTS: Preguideline (n = 54) all subjects were treated with intermittent boluses of diazepam with an average total and maximal individual dose of 248 mg and 32 mg, respectively; 17{\%} were treated with phenobarbital. Forty-seven percent required intubation due to inability to achieve adequate sedation and need for constant infusion of sedative-hypnotics. Intubated subjects had longer length of stay (5.6 vs. 3.4 days; p = .09) and higher incidence of nosocomial pneumonia (42 vs. 21{\%} p = .08). Postguideline (n = 41) there were increases in maximum individual dose of diazepam (32 vs. 86 mg; p = .001), total amount of diazepam (248 vs. 562 mg; p = .001), and phenobarbital use (17 vs. 58{\%}; p = .01). This was associated with a reduction in the need for mechanical ventilation (47 vs. 22{\%}; p = .008), with trends toward reductions in ICU length of stay and nosocomial pneumonia. CONCLUSIONS: Patients admitted to a medical ICU solely for treatment of severe alcohol withdrawal have a high incidence of requiring mechanical ventilation. Guidelines emphasizing escalating bolus doses of diazepam, and barbiturates if necessary, significantly reduced the need for mechanical ventilation and showed trends toward reductions in ICU length of stay and nosocomial infections.",
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T1 - A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens

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AU - Rimal, Binaya

AU - Nolan, Anna

AU - Nelson, Lewis S.

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N2 - OBJECTIVE: Patients with severe alcohol withdrawal and delirium tremens are frequently resistant to standard doses of benzodiazepines. Case reports suggest that these patients have a high incidence of requiring intensive care and many require mechanical ventilation. However, few data exist on treatment strategies and outcomes for these subjects in the medical intensive care unit (ICU). Our goal was a) to describe the outcomes of patients admitted to the medical ICU solely for treatment of severe alcohol withdrawal and b) to determine whether a strategy of escalating doses of benzodiazepines in combination with phenobarbital would improve outcomes. DESIGN: Retrospective cohort study. SETTING: Inner-city municipal hospital. PATIENTS: Subjects admitted to the medical ICU solely for the treatment of severe alcohol withdrawal. INTERVENTIONS: Institution of guidelines emphasizing escalating doses of diazepam in combination with phenobarbital. MEASUREMENTS AND MAIN RESULTS: Preguideline (n = 54) all subjects were treated with intermittent boluses of diazepam with an average total and maximal individual dose of 248 mg and 32 mg, respectively; 17% were treated with phenobarbital. Forty-seven percent required intubation due to inability to achieve adequate sedation and need for constant infusion of sedative-hypnotics. Intubated subjects had longer length of stay (5.6 vs. 3.4 days; p = .09) and higher incidence of nosocomial pneumonia (42 vs. 21% p = .08). Postguideline (n = 41) there were increases in maximum individual dose of diazepam (32 vs. 86 mg; p = .001), total amount of diazepam (248 vs. 562 mg; p = .001), and phenobarbital use (17 vs. 58%; p = .01). This was associated with a reduction in the need for mechanical ventilation (47 vs. 22%; p = .008), with trends toward reductions in ICU length of stay and nosocomial pneumonia. CONCLUSIONS: Patients admitted to a medical ICU solely for treatment of severe alcohol withdrawal have a high incidence of requiring mechanical ventilation. Guidelines emphasizing escalating bolus doses of diazepam, and barbiturates if necessary, significantly reduced the need for mechanical ventilation and showed trends toward reductions in ICU length of stay and nosocomial infections.

AB - OBJECTIVE: Patients with severe alcohol withdrawal and delirium tremens are frequently resistant to standard doses of benzodiazepines. Case reports suggest that these patients have a high incidence of requiring intensive care and many require mechanical ventilation. However, few data exist on treatment strategies and outcomes for these subjects in the medical intensive care unit (ICU). Our goal was a) to describe the outcomes of patients admitted to the medical ICU solely for treatment of severe alcohol withdrawal and b) to determine whether a strategy of escalating doses of benzodiazepines in combination with phenobarbital would improve outcomes. DESIGN: Retrospective cohort study. SETTING: Inner-city municipal hospital. PATIENTS: Subjects admitted to the medical ICU solely for the treatment of severe alcohol withdrawal. INTERVENTIONS: Institution of guidelines emphasizing escalating doses of diazepam in combination with phenobarbital. MEASUREMENTS AND MAIN RESULTS: Preguideline (n = 54) all subjects were treated with intermittent boluses of diazepam with an average total and maximal individual dose of 248 mg and 32 mg, respectively; 17% were treated with phenobarbital. Forty-seven percent required intubation due to inability to achieve adequate sedation and need for constant infusion of sedative-hypnotics. Intubated subjects had longer length of stay (5.6 vs. 3.4 days; p = .09) and higher incidence of nosocomial pneumonia (42 vs. 21% p = .08). Postguideline (n = 41) there were increases in maximum individual dose of diazepam (32 vs. 86 mg; p = .001), total amount of diazepam (248 vs. 562 mg; p = .001), and phenobarbital use (17 vs. 58%; p = .01). This was associated with a reduction in the need for mechanical ventilation (47 vs. 22%; p = .008), with trends toward reductions in ICU length of stay and nosocomial pneumonia. CONCLUSIONS: Patients admitted to a medical ICU solely for treatment of severe alcohol withdrawal have a high incidence of requiring mechanical ventilation. Guidelines emphasizing escalating bolus doses of diazepam, and barbiturates if necessary, significantly reduced the need for mechanical ventilation and showed trends toward reductions in ICU length of stay and nosocomial infections.

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