Reducing the Need for Mechanical Ventilation in Delirium Tremens
Greg Martin, MD, MScA Strategy of Escalating Doses of Benzodiazepines and Phenobarbital Administration Reduces the Need for Mechanical Ventilation in Delirium Tremens
Gold JA, Rimal B, Nolan A, Nelson LS
Crit Care Med. 2007;35:724-730
Summary
Chronic alcohol use is common among hospitalized patients, occurring in at least 10% of intensive care unit (ICU) admissions.[1] Chronic alcohol use may be present in nearly 50% of ICU admissions in certain hospitals and in certain specialties (eg, trauma). Chronic alcohol abuse generally prolongs the length of stay (LOS) in the ICU and hospital, not infrequently from management of delirium tremens (DTs). The study authors sought to determine whether a protocol for managing DTs with the combination of benzodiazepines and barbiturates would improve clinical outcomes. For 54 ICU patients before the institution of the protocol, they observed that 47% required mechanical ventilation, and those patients had a longer ICU LOS (5.6 vs 3.4 days, P = .09) and increased rates of nosocomial pneumonia (42% vs 21%, P = .08). For 41 ICU patients managed after the protocol was put in place, there was greater sedation dosages but fewer patients requiring mechanical ventilation (22%, P = .008) and nonsignificant trends toward shorter ICU LOS (3.8 vs 4.5 days, P = NS) and nosocomial infection (20% vs 31%, P = .10).
Viewpoint
The general recommendation for management of chronic alcohol abuse in the ICU is for diagnostic vigilance (ie, to look for the condition) and close observation of these patients for evidence of alcohol withdrawal syndrome. For alcohol withdrawal delirium and DTs, benzodiazepines are the drug of choice and have been shown to reduce the duration of symptoms and to reduce mortality.[2] However, existing literature suggests that empiric continuous treatment of these patients with sedative drugs to prevent DTs simply prolongs hospital LOS with consequent complications, such as nosocomial pneumonia.[1] Therefore, traditional methods have suggested symptom-triggered dosing rather than fixed or continuous dosing. The results of this study suggest that a protocolized system for symptom-triggered pharmacologic treatment of DTs may prevent complications. Because this system is similar to previous studies showing benefit for symptom-triggered therapy compared with fixed or continuous therapy, and the current study is comparing a more aggressive sedative administration protocol compared with earlier management, the benefit is likely attributable to better patient recognition and management with sedative-hypnotics, rather than from either the medications themselves or even the protocol itself. The take-home message is that identification of patients with chronic alcohol abuse and/or at risk for DTs is important for aggressive and specific interventions to reduce complications of DTs through symptom-triggered pharmacologic therapy.
References
1. Moss M, Burnham EL. Alcohol abuse in the critically ill patient. Lancet. 2006;368:2231-2242.
2. Spies CD, Otter HE, Huske B, et al. Alcohol withdrawal severity is decreased by symptom-orientated adjusted bolus therapy in the ICU. Intensive Care Med. 2003;29:2230-2238.
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