Ciwa problems

[Marsatron]

So an issue I've been having is the general reluctance of some doctors follow CIWA protocol in regards to the treatment of withdrawal with benzos. For example: Pt brought in under the influence of alcohol/meth/thc 3 days ago and is still disoriented to person/place/time with hypertension/tachycardia/diaphoresis. To my eye it seems the sx are related to the withdrawal and continued treatment with benzos is appropriate, while to the doc the sx are related to the benzos and neuro status will be improved by backing off administration. Mind you, patient in question is only recieving 0.5 mg ativan q4h to begin with, and in my view is the withdrawal is being undertreated if anything.

Thoughts? Am I off base here?

[Here.I.Stand, BSN, RN]

Sheesh...what suggestions do they have for the dangerous condition of EtOH withdrawal?? At my facility, pts with a known recent hx, or who have tested positive when brought in are automatically ordered for our Valium protocol.

[LovingLife123]

Well, it's either a little altered mental status or full blown DTs. I'd rather have a little disorientation over seizures any day.

[Cowboyardee]

You'd have to tell me more about exactly what kind of protocol your hospital is using. Most commonly where I am, we see patients on both PRN ativan given at varying doses for their CIWA score along with scheduled librium which is slowly tapered after the worst of the withdrawal symptoms have passed. We don't use valium much but other hospitals do. More severe withdrawal is most often treated with a precedex drip initially.

It really depends on the severity of the withdrawal symptoms and the rest of a patient's underlying condition. Remember that benzo withdrawal is itself quite similar to alcohol withdrawal, and so you might see some minor symptoms of withdrawal as benzos are tapered down. Shouldn't be very severe though if the tapering is appropriately managed. Also note that really severe withdrawal is often associated with persistent delirium either from the benzos themselves, icu associated delirium, or various common underlying conditions (wernekes's encephalopathy, hepatic encephalopathy, etc). Treating these guys and knowing when it is most appropriate to back off the benzos can be a bit more complicated than simply observing for common withdrawal symptoms - especially if you have not really established a good idea of the baseline mental status and medical condition. It's not completely clear from your post, but it seems like you may not be talking about such severe cases in the first place.

Most places have a scale to score the severity of alcohol withdrawal. What happens when you approach your docs with a high withdrawal score and suggest more aggressive withdrawal management? Or do you typically just describe the symptoms to the doc and hope they agree with you?