New Treatment Protocol for New Treatment Protocol for Patient with Alcoholic Patient with Alcoholic WithdrawalWithdrawal

Original Alcoholic Original Alcoholic Withdrawal ProtocolWithdrawal Protocol

Scoring Base OnScoring Base OnHeart rate

Blood Pressure

Temperature

Tremor

Sweating

Convulsion

Hallucination

Sleeplesness

Anxiety

The more patient scores, The more patient scores, the more medication they the more medication they get.get.

Is it appropriate to use this Is it appropriate to use this protocol to be used in protocol to be used in medical or surgical patient?medical or surgical patient?

PROBLEM THAT PROBLEM THAT HAPPENEDHAPPENED

67 years old male

History of Alcoholism and essential tremor

Dx with Atrial Fibrillation , Pneumonia

The patient was put on alcoholic withdrawal protocol.

ProblemProblemPatient continuously scoring

because of high fever, rapid pulse, tremor and high blood pressure

Multiple doses of benzodiazipine were given

Patient score less and finally can rest

RiskRiskHO got notified because patient

become unresponsive to verbal stimuli and has shallow breathing (RR 5/min.)

Patient diagnosed with respiratory failure, intubated and admitted to ICU

Oh,ohhhhhhh

WHAT FACTORS WHAT FACTORS CONTRIBUTE MOST CONTRIBUTE MOST TO SCORING?TO SCORING?

Review of DataReview of Data

Patients admitted to medicine or surgical floor with order for SSA protocol

Data collection: Score for each of factor that lead to administration of benzodiazipine

Factors that most influence Factors that most influence decision to give patient decision to give patient treatmenttreatment

Blood pressure

Pulse rate

Temperature

Tremor

Why did this happen?Why did this happen?

SSA protocol was first designed to use in patient who need alcoholic detoxification

Medical and surgical patient with acute illness will have abnormal vital signs

“Abnormal vital signs may lead to inappropriate scoring and overadministration of benzodiazipine”

New protocol to be usedNew protocol to be used

CIWA-AR ProtocolCIWA-AR Protocol

Rely on subjective symptoms

Don’t use vital signs as a guide to administer benzodiazipine.

CIWA-ARCIWA-ARNausea Vomiting

Tremor

Sweating

Agitation

Hallucination

Anxiety

Role of house officer to Role of house officer to prevent the risk from prevent the risk from using the protocol.using the protocol.

Use the protocol in the patient who need it

Continue follow up patient

Clearly document the history of alcohol consumption

“Data from Mayo Clinic showed that 55% of 124 patients who were put on CIWA-AR protocol had not been drinking!”

Hecksel KA, Bostwick JM, Jaeger TM, Cha S . Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general hospital. Mayo Clin Proc. 2008;83(3):274-279.