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A Symptom-Triggered Benzodiazepine Protocol Utilizing Sas and Ciwa-Ar Scoring for the Treatment of Alcohol Withdrawal Syndrome in the Critically Ill
Sen S, Grgurich P, Tulolo A, et al. Ann Pharmacother. 2017;51:101-10.
Study Question: Will implementation of a protocol with symptom-triggered benzodiazepine (BZD) dosing and assessment of alcohol withdrawal syndrome (AWS) symptom severity using the Clinical Institute Withdrawal Assessment for Alcohol-revised (CIWA-Ar) and Riker Sedation Agitation Scale (SAS) scoring reduce duration of AWS treatment and related complications?
Study Description: This single-center, retrospective study evaluated the effect of a symptom-triggered protocol in adult patients diagnosed with AWS in two medical ICUs from August 2011 to November 2015. Lorazepam treatment was accomplished via the following in the two groups: pre-protocol with a combination of symptom-triggered and fixed dosing according to the CIWA-Ar, with a maximum of 10 mg per hour, resulting in initiation of an infusion titrated to CIWA-Ar < 10 or SAS of 3 to 4; post-protocol: symptom-triggered lorazepam based on CIWA-Ar or SAS, with no maximum hourly dose. Adjunctive therapies were allowed per physician discretion, except for barbituates (exclusion criterion). The primary outcome was duration of AWS treatment, with the end date defined as the first occurrence of either last administration of BZD or documentation of resolution of AWS.
Results: Patients were unequally distributed between pre- (n=135) and post-protocol (n=32) groups. Pre-protocol patients had a lower incidence of cirrhosis (14.8% vs. 37.5%, p<0.01), initial CIWA-Ar score (15.4 vs. 23; p<0.01) and higher Acute Physiology and Chronic Health Evaluation II scores (14.7 vs. 11.3; p<0.01). Fifty percent of the post-protocol patients were assessed using SAS at least once. In the post-protocol group, AWS treatment duration was shorter (5, IQR 4.0-8.0 vs. 8 days, IQR 5.0-12.0; p<0.01), fewer patients were mechanically ventilated (31.3% vs. 57.0%, p=0.01), and shorter ICU (4, IQR 2-7 vs. 7 days, IQR 4-11; p=0.02) and hospital (9, IQR 6-13 vs. 13 days, IQR 9-18; p=0.01) lengths of stay. Post-protocol patients also received lower cumulative dosages of BZDs (74, SD ±159 vs. 450 mg, SD ±701; p<0.01) and BZD continuous infusions (9.4% vs. 58.5%, p<0.01), but more frequent dexmedetomidine (37.5% vs 8.1%, p<0.01). No patients experienced an AWS-associated seizure.
Conclusion(s): The use of a symptom-triggered BZD dosing guideline and assessment of AWS symptom severity using CIWA-Ar and SAS scoring reduced the duration of AWS treatment and AWS-associated complications.
Perspective: This study corroborates results from another single-center study that used escalating doses of BZDs and phenobarbital to achieve light sedation on the Richmond Agitation Sedation Scale score. However, because interventions for benzodiazepine dosing and AWS symptom severity scoring changed simultaneously and SAS usage occurred in only 50% of patients, the results cannot be attributed to either specific intervention alone. Since patients receiving phenobarbital were excluded, institutions employing front-loading of phenobarbital should interpret the results of this study with caution.