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Alcohol Withdrawal in a Hospital Setting

Contact Hours: 4

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Contact Hours: 4

This educational activity is credited for 4 contact hours at completion of the activity.

Course Purpose

The purpose of this course is to provide healthcare professionals with a brief overview alcohol use disorder and withdrawal, including their physiological effects, risk factors, signs of withdrawal, and how withdrawal is diagnosed and treated, in addition to providing important nursing considerations when caring for the alcohol dependent patient.

Overview

Alcohol use disorder is characterized by an unrelenting pattern of drinking that leads to distress or impairment, with symptoms ranging from mild to severe. Alcohol withdrawal is a cluster of symptoms experienced by an individual with sustained alcohol use once alcohol consumption suddenly decreases or is stopped. This course examines alcohol use disorder and withdrawal, discussing their physiological effects, risk factors, signs of withdrawal, and how withdrawal is diagnosed and treated, in addition to providing important nursing considerations when caring for the alcohol dependent patient.

Course Objectives

Upon completion of the independent study, the learner will be able to:

  • Describe alcohol use disorder and alcohol dependency behaviors.
  • Describe the central nervous system effects of ethanol, and the physiological effects of alcohol withdrawal.
  • Identify symptoms of alcohol withdrawal.
  • Review factors associated with an increased risk of alcohol withdrawal in an alcohol dependent person.
  • Understand common modalities of treatment for symptoms of alcohol withdrawal.

Policy Statement

This activity has been planned and implemented in accordance with the policies of FastCEForLess.com.

Disclosures

Fast CE For Less, Inc and its authors have no disclosures. There is no commercial support.

Fast Facts: Alcohol Withdrawal in a Hospital Setting

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Definitions
AbsorptionThe process of absorbing something or of being absorbed.
Alcohol Use DisorderA pattern of alcohol use that involves problems controlling your drinking, being preoccupied with alcohol, or continuing to use alcohol even when it causes problems.
Alcohol Withdrawal SyndromeA set of symptoms that occur when someone who is physically dependent upon alcoholsuddenly stops drinking or drastically reduces their alcohol intake.
Alcohol WithdrawalThe name for the symptoms that occur when a heavy drinker suddenly stops or significantly reduces their alcohol intake.
AnticonvulsantsDrugs that help to normalize the nerve impulses along the nerve cells and prevent or treat seizures, nerve pain and bipolar disorder.
Autonomic HyperactivityA life-threatening condition that affects the sympathetic and parasympathetic systems of the nervous system.
BenzodiazepinesDrugs that can calm the brain and body by enhancing a chemical called GABA.
Central Nervous System (CNS) DepressantDrugs that can slow brain activity, making them useful for treating anxiety, panic, acute stress reactions, and sleep disorders. 
Central Nervous System (CNS)Consists of the brain and spinal cord.
Delirium Tremens (DT)A life-threatening condition caused by sudden alcohol withdrawal in heavy drinkers.
DownregulationThe process of reducing or suppressing a response to a stimulus, such as a decrease in the number of receptors on the cell surface. 
EthanolA flammable, colorless liquid with a characteristic wine-like odor and pungent  taste.
GABAergicPertains to or affects the neurotransmitter gamma-aminobutyric acid (GABA).
Gamma-Aminobutyric Acid (GABA)A neurotransmitter, a chemical messenger in the brain that slows down the brain by blocking specific signals in the central nervous system.
Generalized Tonic-Clonic SeizuresA seizure that originates in both halves (hemispheres) of the brain simultaneously, causing stiffness or twitching throughout the body.
GlutamateA chemical messenger that helps nerve cells communicate in the brain and other tissues.
HypercapniaA condition of too much carbon dioxide in the bloodstream that can cause dizziness, fatigue, and shortness of breath. 
HypoglycemiaA condition resulting when the blood glucose levels drop below the specified limit.
HypoxiaA below-normal level of oxygen in the blood, specifically in the arteries. 
KindlingA process by which a seizure or other brain event is both initiated and its recurrence made more likely.
Korsakoff’s SyndromeA brain and memory disorder that is caused by a severe lack of thiamine (vitamin B1).
NeurotransmitterThe body’s chemical messengers that transmit signals between nerve cells and other cells.
SeizuresA sudden surge of electrical activity in the brain that can affect how a person feels, thinks, or acts.
Up-RegulatedThe process of increasing the response to a stimulus.
Wernicke’s EncephalopathyThe presence of neurological symptoms caused by biochemical lesions of the central nervous system after exhaustion of B-vitamin reserves, in particular thiamine (vitamin B1).
Introduction

Alcohol withdrawal is a cluster of symptoms experienced by an individual with sustained alcohol use once alcohol consumption suddenly decreases or is stopped.1 Also known as alcohol withdrawal syndrome, it is a common problem in hospitals and emergency rooms, with reports estimating that 55% of hospitalized medical patients with an alcohol use disorder (AUD) will experience alcohol withdrawal while in care. The reported mortality rate for such patients typically ranges between 1 to 5%.2

The healthcare impact of treating alcohol abuse and its withdrawal symptoms is substantial, leading to significant economic costs related to medical expenses and treatment as it often encompasses various interventions, including medications and rehabilitation programs.1

The cost of AUD treatment varies based on the level of care required, but it goes as high as thousands of dollars per episode, depending on factors such as the  duration and intensity of treatment. According to a review in the American Journal of Public Health, the estimated medical costs attributable to treating excessive alcohol consumption in the United States averaged over $25 billion.3,4

This course examines alcohol use disorder and withdrawal, discussing their physiological effects, risk factors, signs of withdrawal, and how withdrawal is diagnosed and treated, in addition to important nursing considerations when caring for the alcohol dependent patient.

Define Alcohol Use Disorder

Alcohol use disorder (AUD) refers to a pattern of harmful drinking and excessive behaviors that lead to negative consequences in various areas of an individual’s life, including health, social relationships, work or school performance, and overall well-being.5

The National Survey on Drug Use and Health (NSDUH) reports that on average, 29 million Americans, age 12 and older have experienced AUD in the past year. Alcohol use disorder contributes to a substantial number of accidents and fatalities, accounting for over 140,000 alcohol-induced and related deaths, making alcohol the fourth-leading preventable cause of death in the United States.3,4

Alcohol, chemically known as ethanol, affects the body through various mechanisms due to its central nervous system (CNS) depressant properties. When consumed, alcohol undergoes absorption, distribution, metabolism, and elimination processes that impact multiple physiological systems.5

In the CNS specifically, ethanol acts as a GABAergic that directly affects and depresses the inhibitory neurotransmitter, gamma-aminobutyric acid (GABA), causing slowed reaction times, impaired coordination, and altered cognitive functions.5 Chronic alcohol consumption leads to permanent downregulation of GABA receptors. To maintain balance in the system, glutamate, GABA’s excitatory counterpart, is up-regulated and stabilized at a much higher level.1,5,6

This is the brain’s way to counter the depressive effects of ethanol and maintain normal levels of brain activity. Over time, the body becomes reliant on ethanol, needing it to maintain this new balance, thus encouraging more consumption, and addiction.1,5,6

Alcohol Dependency Behaviors

Individuals with alcohol dependency, also known as alcohol use disorder (AUD), exhibit a range of behaviors that reflect their compulsive and problematic relationship with alcohol. Alcohol use disorder is characterized by an unrelenting pattern of drinking that leads to distress or impairment, with symptoms ranging from mild to severe. Common behaviors associated with alcohol dependency include strong desires or cravings for alcohol, leading to an overwhelming urge to drink.5

These cravings also make it difficult for such people to control the amount and duration of alcohol consumption, often leading to consumption beyond intended limits. As a result, they develop tolerance, requiring increased amounts of alcohol to achieve the same “drunk” effects or experiencing reduced effects when consuming the same amount.5

Someone with alcohol dependency will also devote a significant amount of time to obtaining, consuming, or recovering from the effects of alcohol, even when consuming alcohol is against better judgment, such as when it is physically hazardous, like while driving, operating machinery, or in activities requiring attention and coordination.5

Such individuals may also lose interest in hobbies, and once enjoyable activities. Other social changes include reducing or stopping participation in important social, occupational, or recreational activities. The resulting self-isolation from family, friends, or social activities may be to pursue further drinking, or due to embarrassment about one’s drinking behavior.5

Despite negative consequences, a person with an alcohol dependency continues to drink. While they may attempt to reduce or control alcohol consumption repeatedly, it will often be without success as serious withdrawal symptom makes it difficult 5

A person with an alcohol dependency may hide their drinking or lie about the amount consumed. When confronted, they typically become defensive or deny the extent of their consumption when confronted by others.5

Define Alcohol Withdrawal

Alcohol withdrawal is often seen in those who consume large quantities of alcohol, consume alcohol frequently, or are chronic alcohol users, as their central nervous system (CNS) has become accustomed to the presence of alcohol.1,6

Such patients will have altered neurotransmitter functionality to maintain system balance, such that GABA receptors are desensitized and downregulated, and glutamatergic receptors are over-activated.1,6

When alcohol intake abruptly decreases or stops, this balance is suddenly disrupted. GABA is no longer inhibited, and the CNS is extremely hypersensitive to the higher levels of glutamate, leading to a jump in brain excitability.1,6

Without alcohol to reestablish the intoxicated balance, neurotransmitter activity is out of control, escalating unregulated, resulting in a hyper-excitable state. This state manifests as a range of physiological and neurological symptoms. 1,6

The severity of these symptoms and their associated complications vary from patient to patient, as chronic or heavy alcohol consumption affects multiple physiological processes causing problems in liver metabolism, malnutrition, cardiovascular impairments, hormonal disruptions, immune system suppression, and gastrointestinal issues. 1,6

Risks of Alcohol Withdrawal

If a patient with alcohol withdrawal is left unmanaged or is not treated promptly, symptoms can progress and become serious complications. It is estimated that up to 5% of patients experiencing alcohol withdrawal experience serious complications such as delirium tremens (DT), seizures, and cardiovascular instability.1,6 Moreover, patients with alcohol withdrawal often suffer from electrolyte imbalance from the profuse sweating, vomiting, and diarrhea associated with this condition. This can lead to sodium, potassium, and magnesium deficiencies, triggering other neuromuscular problems such as impaired coordination, cognitive disturbances, and potential seizure activity, increasing the risk of injuries.1,6

In severe cases of alcohol withdrawal, especially during DT or when combined with other sedative use, respiratory depression can occur. This condition involves slowed or shallow breathing, leading to hypoxia (low oxygen levels) and hypercapnia (high carbon dioxide levels) in the blood.1,6 All of these complications are often accompanied by psychological symptoms that can progress to full-blown psychosis, with delusions, paranoia, and aggressive behavior.1,6

Signs of Alcohol Withdrawal

A patient with alcohol withdrawal may present with several symptoms resulting from the sudden hyperactivity of their central nervous system (CNS). These symptoms may arise within hours to days of alcohol cessation. The most common signs and symptoms include autonomic hyperactivity, tremors, anxiety and restlessness, insomnia, nausea and vomiting, hallucinations, seizures, and delirium tremens.1,5,6,7

Autonomic Hyperactivity

Autonomic hyperactivity is among the most prevalent symptoms, characterized by a collection of involuntary excitation responses, including tachycardia (increased heart rate), hypertension (elevated blood pressure), diaphoresis (profuse sweating), and dilated pupils. Headaches and elevated body temperature may also be present.1,5,6,7

Tremors

Tremors are also common, particularly in the hands, but they may also be noted in other areas and limbs of the body. The severity of these tremors varies widely among patients and depends on the duration and intensity of alcohol consumption.1,5,6,7

Anxiety and Paranoia

Anxiety and paranoia are prominent psychological symptoms seen. They are often accompanied by restlessness, constant agitation, and the inability to remain calm. The altered neurotransmitter modulation disrupts the internal sleep-wake cycle, which also causes disturbed sleep patterns and insomnia.1,5,6,7

Nausea, Vomiting, and Diarrhea

Nausea, vomiting, and diarrhea are also frequently encountered. These symptoms arise from the dysregulation of autonomic function and can contribute to overall discomfort.1,5-7

Auditory, Visual, or Tactile Hallucinations

Auditory, visual, or tactile hallucinations are also experienced in moderate to severe cases. Such patients claim they can see, hear, or feel manifestations that are not present.

Seizures

Seizures are also seen in a subset of patients and can vary in severity from focal to generalized tonic-clonic seizures (grand mal seizures). Seizures indicate a pronounced hyper-excitability, and if there are multiple seizures, it may signal an escalation into delirium tremens.1,5,6,7

Delirium Tremens (DT)

Delirium Tremens (DT) is a rare but life-threatening complication of alcohol withdrawal. It is characterized by hallucinations, fluctuating consciousness, disorientation, hyper-agitation, and autonomic instability, including fever and profound cardiovascular irregularities. If DT is not managed immediately and sufficiently, it can result in death.1,5,6,7

Diagnosing Alcohol Withdrawal

Typically, alcohol withdrawal is diagnosed based on two criteria:6

  • Clear evidence of recent alcohol cessation or significant reduction following prolonged or high-volume use.
  • The presentation of the common symptoms is not caused by another medical condition, behavioral disorder, or mental disorder.

Reaching a diagnosis requires taking a comprehensive history of the frequency and amount of alcohol consumed as well as the time elapsed time between the last alcohol intake and the onset of withdrawal symptoms.8 If the time elapsed is more than two weeks after stopping alcohol consumption, the connection of the aforementioned symptoms to alcohol withdrawal syndrome becomes questionable, regardless of alcohol use. For accurate assessment and diagnosis, most healthcare facilities use screening tests such as the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale.8

Clinical Institute Withdrawal Assessment for Alcohol (CIWA) Scale

The Clinical Institute Withdrawal Assessment for Alcohol (CIWA or CIWA-AR for the revised version), is a 10-item scale that assigns points 0 – 7 to each item independently. These points are aggregated to yield a score that relates to the severity of alcohol withdrawal.9

The ten items on the scale are (1) nausea and vomiting, (2) tremors, (3) paroxysmal sweats, (4) anxiety, (5) agitation, (6) tactile disturbances, (7) auditory disturbances, (8) visual disturbances, (9) headache, and (10) orientation and clouded sensorium.9

The maximum score is 67, with mild alcohol withdrawal scoring less than or equal to 10, moderate between 11 – 15, and severe greater than or equal to 16.9

Diagnosing Mild Alcohol Withdrawal

Mild alcohol withdrawal typically starts six hours after stopping or reducing alcohol intake and can last up to 48 hours. The most common symptoms include autonomic hyperactivity (tachycardia, hypertension, diaphoresis), tremors, nausea, vomiting, headaches, and anxiety, however, orientation is intact.8

Diagnosing Moderate to Severe Alcohol Withdrawal

Along with common symptoms seen in mild cases of alcohol withdrawal, moderate to severe cases will also include hallucinations that may last up to 6 days and  generalized tonic-clonic seizures that begin within 6 – 48 hours after cessation of alcohol consumption.8

If multiple seizures (up to 6) occur within 6 hours, there is an elevated risk of DTs occurring. In such cases, DTs may present 48 – 72 hours after alcohol cessation and may last up to two weeks.8

Risk Factors

Several risk factors contribute to the development of alcohol withdrawal, leading to certain patient populations having a higher likelihood of more serious symptoms. These key risk factors are given below.

Quantity, Frequency, and Duration of Alcohol Use

Patients who have engaged in heavy and prolonged alcohol consumption or consume greater quantities of alcohol are at the highest risk of severe withdrawal symptoms. In such cases, the brain has significantly made neuro-adaptive changes to manage the presence of alcohol in the body. Once alcohol intake suddenly decreases, such patients experience the most drastic disruptions.1,5,6

History of Withdrawal

A prior history of alcohol withdrawal increases the risk of more severe symptoms upon subsequent cessation of alcohol intake. This phenomenon, also known as kindling, is believed to be related to the sensitization of the brain’s withdrawal pathways due to repeated episodes of withdrawal and alcohol exposure. Kindling can quickly build, causing serious complications.10 For example, patients who are binge drinkers may not experience withdrawal symptoms initially. Still, with each cycle of alcohol use and cessation, withdrawal symptoms will intensify in severity and may eventually result in full-blown delirium tremens with convulsive seizures.10  In addition, patients who experienced seizures during previous detoxification are more likely to have them again than those who have not had seizures during alcohol withdrawal.10

Abrupt Cessation

Suddenly stopping alcohol consumption, especially in patients with an elevated level of dependence, can trigger more severe and sudden-onset withdrawal symptoms. For such patients, gradual tapering of alcohol intake under medical supervision is recommended to mitigate the risk of severe withdrawal.10

Nutritional Deficiencies

Chronic alcohol consumption often leads to deficiencies and malnutrition in necessary vitamins and minerals, such as thiamine (vitamin B1). These nutritional deficiencies can exacerbate the neurological and cognitive symptoms associated with withdrawal, leading to conditions like Wernicke’s encephalopathy and Korsakoff’s syndrome.10

Co-Existing Medical Conditions

Patients with certain co-morbidities, such as liver disease, cardiovascular disease, diabetes, epilepsy, and psychiatric disorders, are at an elevated risk for more severe and complicated withdrawal symptoms. These medical conditions can interact with the physiological effects of alcohol withdrawal, exacerbating symptoms.10 For example, a patient with co-existing diabetes is more likely to have episodes of hypoglycemia which interact with other metabolic processes and exacerbate symptoms.10

Age and Gender

Older patients and women may be more susceptible to severe alcohol withdrawal symptoms due to differences in metabolism, hormonal factors, and age-related changes in brain function.10

Genetic Predisposition

Genetic factors also determine whether a patient is vulnerable to alcohol dependence and withdrawal. Variations in genes that influence alcohol metabolism and neurotransmitter function can impact how a patient experiences withdrawal symptoms.10

Polysubstance Abuse

Concurrent use of other substances, especially drugs, and sedatives that affect the CNS, can complicate alcohol withdrawal. These substances can interact with the withdrawal process, intensifying symptoms or leading to unpredictable reactions.10

Social Support

Lack of a strong support system and environmental stressors can contribute to the severity of alcohol withdrawal. Emotional distress and an absence of social support can also worsen psychological symptoms.10

Treatment Options

Treatment for alcohol withdrawal is detoxification that is focused on three objectives: (1) to provide a safe withdrawal, (2) to provide humane withdrawal, and (3) to prepare the patient for continuing treatment.11  For this reason, supportive care-only protocols are typically not used, and medication is recommended for all cases of alcohol withdrawal. This makes the detoxification process more comfortable for patients and avoids the risks of serious complications.12

Benzodiazepines

The standard medication used to treat alcohol withdrawal is benzodiazepines. This class of drugs mimics the effects of alcohol on the central nervous system by stimulating the GABA receptors in the brain, decreasing neuronal activity, and causing sedation. By gradually reducing the dosage of the benzodiazepine, patients can slowly be weaned off alcohol through a safer detoxification process.13

The benzodiazepines most used are diazepam, lorazepam, oxazepam and chlordiazepoxide. All of these have been shown to be equally effective in treating alcohol withdrawal. The choice depends on its effects on the specific patient. Chlordiazepoxide and diazepam are long-acting agents, while lorazepam and oxazepam are comparatively short-acting.1,6,8,13

  • Long-acting benzodiazepines
    • Long-acting benzodiazepines remain in the system longer for a prolonged effect, providing a smoother recovery and less risk of withdrawal symptoms. However, this can also lead to drug accumulation in certain patients, such as those with liver disease.13
  • Short-acting benzodiazepines
    • Short-acting benzodiazepines have a shorter half-life but are more efficacious. Therefore they are better suited for patients with liver dysfunction or are at a higher risk of medical complications following sedation, such as the elderly or those with severe lung disease. However, this shorter half-life also means a higher risk of withdrawal symptoms. To prevent this recurrence, short-acting agents are given in tapered doses before discontinuing.13

Benzodiazepines Treatment Protocols

Several treatment protocols are used for alcohol withdrawal, but the most common are fixed-dose, symptom-triggered, and loading dose.1,6,8,13 

Fixed-dose protocol

  • Fixed-dose protocol administers a standard dose of benzodiazepine following a fixed schedule, regardless of the severity of withdrawal symptoms. The initial dose is determined by the presenting symptoms and the time duration since the last alcohol consumption. Typically, starting doses begin at 20 mg of diazepam in mild cases.13   This protocol is recommended for patients where withdrawal cannot be assessed because of co-morbidities, psychiatric illnesses, use of other medications, or lack of staff training.13 

Symptom-triggered protocol

  • Symptom-triggered protocol administers doses based on objectively measured signs and symptoms. These symptoms are measured on a fixed schedule, and doses are adjusted accordingly. Overall, less medication is given, resulting in fewer complications and shorter lengths of stay. However, this is approach is clearly defined, requiring extensive staff training in assessing the withdrawal presentation and applying scales to doses.13

Loading dose protocol

  • Loading dose protocol administers long-acting benzodiazepines immediately and every two hours to reduce the risks of serious complications, regardless of presenting symptoms. However, the patient’s condition needs to be assessed before each dose.13 

Seizures and Delirium Tremens

Seizure and delirium tremens are critical conditions that require immediate treatment and close monitoring. Management focuses on achieving a calm, awake state using benzodiazepines. A further high dose of benzodiazepines, such as 20 – 60 mg of diazepam, may be necessary for more seizures and DT development.7,14 Alternatively, lorazepam may be given intravenously. Lorazepam is favored in hepatic patients and the elderly. An initial dose of 2 – 2.5 mg of lorazepam is given intravenously or intramuscularly every 15-30 minutes. This line of treatment is also recommended for patients with a history of withdrawal seizures.14

Anticonvulsants

Recent findings suggest anticonvulsants such as carbamazepine, gabapentin, and vigabatrin may be suitable alternatives for treating alcohol withdrawal in patients with mild to moderate symptoms. Research has shown they may reduce the risk of withdrawal, seizure, and cravings without the same sedative effect as benzodiazepines and are much less likely to be abused. They are also an effective treatment for mood disorders, such as depression, irritability, and anxiety, which are symptoms of alcohol withdrawal.1,5

However, anticonvulsants interact with multiple medications, making them unsuitable for patients with co-morbidities and older patients. Also, there is insufficient evidence to determine its effectiveness in treating alcohol withdrawal seizures and delirium tremens. 1,5

Multivitamins and Electrolyte Replacement

Multivitamins and electrolyte replacement have now become part of standard treatments. Alcohol-dependent patients, especially those with poor diet and signs of malnutrition, are typically deficient in vitamins and electrolytes, such as thiamine (vitamin B1), riboflavin (vitamin B2), niacin (vitamin B3), pyridoxine (vitamin B6), folic acid (vitamin B9) and magnesium.1,5,13 These deficiencies increase the risk of Wernicke’s encephalopathy (WE), an acute neurological disorder characterized by confusion, ataxia (loss of coordination), oculomotor disturbances, and altered mental states.16

If Wernicke’s encephalopathy is left untreated, it may progress and cause a chronic neuropsychiatric disorder known as Korsokoff’s syndrome. This syndrome leads to long-lasting cognitive impairments such as memory deficits, fabricated memories, and difficulty forming new memories, significantly affecting daily functioning and social interactions.17

  • For patients without WE – One multivitamin tablet along with oral or intravenously 100 mg thiamine and 1 mg folic acid per day may be administered for 7 – 14 days.1,5,17
  • For patients with suspected WE – The thiamine dose should be increased to 500 – 1500 mg administered via IV three times a day for 3—5 consecutive days.17

Adjunctive Treatments

Depending on the severity and symptoms of the alcohol, additional treatments may be recommended.

For patients with androgenic hyperactivity, such as hypertension, despite benzodiazepine treatment, adjunctive antihypertensive drugs such as clonidine may be necessary. Doses typically range from 0.2 – 1.2 mg, as higher doses increase the risk of adverse reactions.1,6,13

Dexmedetomidine has also been suggested as an alternate, but the findings are limited.15

For patients experiencing delirium despite benzodiazepine treatment, antipsychotics such as haloperidol may be administered orally or by intramuscular injection. Adverse effects include masking other withdrawal symptoms and the increased risk of restlessness, agitation, and seizures.1,5,6

Nursing Considerations

Even in mild cases of alcohol withdrawal, the detoxification process is uncomfortable. Patients will need supportive care throughout detoxification, in addition to medication to treat symptoms.1,6,7,13 Therefore, it is essential to provide comfort and relaxation for patients. They should preferably be kept in a quiet room with minimal stimulation and low lighting. As dehydration is an important concern, IV electrolyte fluids with vitamin supplements are typically given prophylactically to prevent progression.1,6,7,13

Patients experiencing mild alcohol withdrawal may not require prolonged pharmacotherapy. Supportive care may be sufficient with a loading dose to provide sedation. The patient should also be kept in a quiet, calm environment where they can manage their symptoms. Observation for up to 36 hours is advised, after which the patient is unlikely to develop further symptoms.1,6,7,13

If a patient has risk factors, such as a history of severe withdrawals or acute medical illness, longer treatment with benzodiazepines may be needed. Close monitoring is essential as further dosing may be required if other withdrawal symptoms appear.1,6,7,13

For patients with moderate to severe withdrawal, medications should be administered immediately, along with fluids, to manage dehydration. If seizures have not presented, monitoring is recommended. Patients with an elevated risk of developing seizures should still be given intravenous access. This access ensures immediate management if withdrawal progresses. If patients have seizures or have a history of seizures, the alcohol withdrawal is considered severe and preventative management is needed to prevent DT.1,6,7,13

While restraints should be avoided in all cases, they may be necessary in cases of extre

Measures to Reduce Risks of Fetal Complications

Cases of preeclampsia and HELLP syndrome are difficult to predict. While certain risk factors increase the likelihood of developing either of these conditions, there is no definitive screening test.1, 2 At most, screening practices can identify high-risk pregnancies by checking blood pressure and protein levels in the urine. Additionally, fetal growth can be closely monitored for signs of restrictive growth. In the case of any concern, antenatal care can be adjusted to prevent symptoms from progressing.3, 4, 18

Other preventative measures that can be taken to reduce the risk of fetal complications include lifestyle changes a woman can make before pregnancy to reduce the risks of developing either preeclampsia or HELLP syndrome. These lifestyle changes include consuming a nutrient-rich diet and maintaining a healthy weight.26

Secondary preventative medical interventions are currently under research that can be used to disrupt known pathophysiological mechanisms of these disorders before they are established and avoid complications.27, 28 For example, low-dose aspirin has been suggested for women with a history of preeclampsia after 12 weeks of pregnancy to reduce the likelihood of recurrence.27

Nursing Considerations

A pregnant or postpartum woman with preeclampsia or HELLP syndrome can rapidly deteriorate and become critically ill, resulting in life-threatening medical emergencies. Once symptoms present, management and monitoring are critical.1, 2 The pregnant woman’s blood pressure must be monitored closely, along with oxygen saturation. Blood and urine samples must also be sent for testing regularly to check platelet count, liver function, and protein levels. Neurological exams must be performed frequently to prevent any impairments in consciousness. 1, 2, 26  

Medications may be prescribed to reduce high blood pressure and prevent seizures, which must be administered routinely. If anticonvulsants are given, the patient’s reflexes should also be monitored.

In addition to the mother’s health, fetal health must also be monitored. This includes regularly checking fetal heart rate to ensure the fetus is not in distress and monitoring fetal growth to check for signs of growth restriction or any other abnormalities. 1, 2, 26

If there is any altered state of consciousness, decreased urine output, or consistent elevated blood pressures, healthcare providers must begin treatment immediately to reduce the severity of preeclampsia or HELLP syndrome.1, 2, 26

Conclusion

Alcohol withdrawal is a complex and potentially serious medical condition that requires careful assessment, intervention, and management, especially in a hospital setting. The prevalence of alcohol withdrawal syndrome among hospitalized patients underscores the importance of healthcare professionals knowing about its physiological mechanisms, risk factors, signs, and treatment options.

Understanding the behaviors of individuals with alcohol dependency is key for timely identification and appropriate care. These individuals often exhibit various behaviors such as cravings, loss of control, tolerance, and continued use despite negative consequences. Given such individual reluctance to admit their dependency comprehensive assessment is to diagnose the severity of alcohol withdrawal.

While tools such as the CIWA scale aid in accurately assessing the severity of symptoms, it is also important to weigh the risk factors to take pre-emptive measures.

Treatment for alcohol withdrawal involves a combination of pharmacological interventions, supportive care, and addressing nutritional deficiencies. Benzodiazepines, electrolyte replacement, and multivitamin supplements remain the mainstay of treatment, effectively managing symptoms and preventing serious medical emergencies such as seizures and delirium tremens. Adjunctive treatments such as anticonvulsants may be considered based on individual patient needs.

Ensuring patient comfort and safety throughout the detoxification process is another facet of treatment and involves providing a calm environment, administering medications appropriately, and closely monitoring the progress of symptoms.

By understanding the complexities of alcohol withdrawal and tailoring interventions to individual patient needs, healthcare professionals can contribute to safer and more successful outcomes for patients experiencing alcohol withdrawal in a hospital setting.

References
  1. Hawkins, E. (2018). Alcohol withdrawal symptoms: A quick aid to safe and smooth recovery from alcohol and alcoholism withdrawal symptoms. Independently Published.
  2. Schuckit, M. A. (2014). Recognition and Management of Withdrawal Delirium (Delirium Tremens). New England Journal of Medicine, 371(22), 2109–2113. https://doi.org/10.1056/nejmra1407298
  3. Alcohol Use Disorder (AUD) in the United States: Age Groups and Demographic Characteristics | National Institute on Alcohol Abuse and Alcoholism (NIAAA). (2023). Www.niaaa.nih.gov. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-use-disorder-aud-united-states-age-groups-and-demographic-characteristics
  4. Alcohol-Related Emergencies and Deaths in the United States | National Institute on Alcohol Abuse and Alcoholism (NIAAA). (2023). Www.niaaa.nih.gov. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-related-emergencies-and-deaths-united-states
  5. American Psychiatric Association. (2018). The American psychiatric association practice guideline for the pharmacological treatment of patients with alcohol use disorder. American Psychiatric Pub.
  6. Czarnik, S., Kocan, M. J., Strobbe, S., Alaniz, C., Ciarkowski, S., Kirst, N., Lukela, M., Malloy, K., Seyfried, L., Somand, D., Walker, P., Wood, W., & Seagull, F. J. (2020). Alcohol Withdrawal in Hospitalized Patients: Michigan Alcohol Withdrawal Severity (MAWS) Protocol. In PubMed. Michigan Medicine University of Michigan. https://www.ncbi.nlm.nih.gov/books/NBK555603/
  7. Grover, S., & Ghosh, A. (2018). Delirium Tremens: Assessment and Management. Journal of Clinical and Experimental Hepatology, 8(4), 460–470. https://doi.org/10.1016/j.jceh.2018.04.012
  8. Bharadwaj, B., & Kattimani, S. (2013). Clinical management of alcohol withdrawal: A systematic review. Industrial Psychiatry Journal, 22(2), 100. https://doi.org/10.4103/0972-6748.132914
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  10. Jesse, S., Bråthen, G., Ferrara, M., Keindl, M., Ben-Menachem, E., Tanasescu, R., Brodtkorb, E., Hillbom, M., Leone, M. A., & Ludolph, A. C. (2016). Alcohol withdrawal syndrome: mechanisms, manifestations, and management. Acta Neurologica Scandinavica, 135(1), 4–16. https://doi.org/10.1111/ane.12671
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