How are you assessing alcohol withdrawal?

[nj3456]

The Unit Based Shared Governance committee at the hospital at which I'm working is looking to explore why we're having such high rates of patients going into severe DTs, requiring high-dose Ativan drips. Through a little research, I'm convinced it may be as simple as us not using CIWA protocols. There was an attempt to roll this out two years ago, but there wasn't any education on it, so it failed (as in, nurses were refusing to use it and sticking with our fixed dose/fixed schedule dosing).

What are you using at your hospital - fixed dose/schedule (for example, Q6 Librium around the clock with PRN Ativan), or CIWA? Are people becoming too over-sedated with CIWA? Feel free to add anything relevant - are your docs OK with Haldol as an adjunct? Phenobarbital?

For MICU nurses, are you using Precedex? Is your protocol that they need to be intubated for Precedex? Either way, do you feel that it works?

Thank you for your input! :)

[waiting4ivpush]

Only read the title.

My answer: More alcohol

[nj3456]

Lol, re-titled now for clarity.

[Dogen]

We use CIWA with either Ativan or Librium on my psych unit. I brought this up recently in another thread: in my experience RNs are frequently not following the protocol because they're worried about sedating the patient, when in fact some level of sedation is the goal. I've never studied it systematically, but I think they tend to overestimate the risk of sedation from benzos (that is, being unaware that it's very hard to kill someone with only benzos). I've had nurses be nervous about giving 50mg of Librium q2-4hr, not aware that during DTs a patient may get 50-100mg q1hr, or 2-4mg of Ativan q15min.

Anyway, the answer is always to follow the evidence, and right now the evidence says the best intervention is therapy triggered by a patient's symptoms, such as the CIWA. Research has shown that people who get fixed doses/schedules tend to get more meds and are hospitalized longer.

[Farawyn]

Lol, re-titled now for clarity.

It's in direct correlation to my desire for bacon, egg and cheese on a roll and a Snapple.

[ixchel]

We use WAS, with an initial huge stat dose of Ativan or Librium. I tend to see Ativan used more often than Librium. I usually hold that stat dose until they stop having a zero on the scale. Once they start to climb over 10, we have PRNs q1h and q2h (yes, both). The q2h is labeled to give for anxiety. I agree that the point is to produce some sedation. ETOH withdrawal is life threatening. It would be good to prevent it from getting so severe if you can.

We had one guy who took 15 days to get past his withdrawal. His ammonia level just wouldn't drop. This guy ended up intubated on day one, but his withdrawal was so profound, no amount of sedation would actually sedate him. He ended up extubating himself. He assaulted and spit at everyone. His apparent superhuman strength would pull the restraints free. SCARY doesn't even begin to describe it.

Incidentally, when I got him on my unit, he groped me a couple of times. It's probably the first time ever that I've actually thought, "thank god he groped me." I was beyond glad he didn't get violent. Two shifts prior, he'd gotten a total of 25 mg Ativan and was still throwing punches.

Some people are just going to have it horrible no matter what you do. He's lucky he survived.

Had another guy who had a giant bottle of oxy on him. Didn't find it until 10 hours after his initial dose of Ativan when he didn't wake up for the entire day and he had to be straight cathed (which we changed to a foley because he had a significant blockage in his member - yes, I mean member, not at his prostate). We ended up Narcanning him and suddenly he was a&o. His detox was relatively mild, but he did begin the dialysis journey that admission.

(Moral of that story - make sure the patient has been searched, if they allow it.)

I feel like your facility's education department needs to review some EBP on withdrawal and create a good education piece on this. These nurses will not only make this easier on the patient (who is going through hell during this), but they'll make it easier on them as well. A shift without active DTs is a much, much easier shift.

[ixchel]

I just tried to google WAS and didn't find it. Not sure if it's just our assessment or if Google sucks. It's similar to CIWA but also includes mental status questions and tactile disturbances.

[Jules A, MSN]

We use CIWA with either Ativan or Librium on my psych unit. I brought this up recently in another thread: in my experience RNs are frequently not following the protocol because they're worried about sedating the patient, when in fact some level of sedation is the goal. I've never studied it systematically, but I think they tend to overestimate the risk of sedation from benzos (that is, being unaware that it's very hard to kill someone with only benzos). I've had nurses be nervous about giving 50mg of Librium q2-4hr, not aware that during DTs a patient may get 50-100mg q1hr, or 2-4mg of Ativan q15min.

Anyway, the answer is always to follow the evidence, and right now the evidence says the best intervention is therapy triggered by a patient's symptoms, such as the CIWA. Research has shown that people who get fixed doses/schedules tend to get more meds and are hospitalized longer.

This. It frustrates me to no no end that RNs, especially in psychiatry where we see this all the time, are so resistant to give adequate doses of benzos despite being clearly instructed that in certain cases sedation is the goal. I get that it is drilled into our heads that over sedation is bad and there is concerns of falls risks when patients are sedated but seriously folks this is a totally different situation. Try getting control of full blown DTs it isn't easy or pretty.

I order CIWA with Ativan or Valium depending on their liver and kidney function. In patients who are likely to go into withdrawal I will also do a standing order taper which I watch closely and reduce as indicated. While they may get more medication, which I'm not convinced of if in fact they were receiving the CIWA prns appropriately, they do not at least anecdotally have longer hospitalizations. Although the research does not show better overall results my thought is it makes the patient more comfortable in that they hopefully aren't having higher CIWA scores prior to being medicated. For those nurses hesitant to give a benzo, for whatever reason, the patient isn't going into full blown DTs before they are medicated. I'm not a fan of Librium unless I'm doing a 1 time dose to send someone home who might not be finished withdrawal. The 1/2 life is so long that if they are overly sedated it will take longer to clear.

OP I recommend CIWA but also educating RNs on the rationale and protocol. The other thing is making them aware of the ss of benzo or alcohol wd in medical floor patients with no reported history. This happens often in people who are closet drinkers or abuse their benzos and the signs are fairly easy to recognize. If you have a patient who has been hospitalized a couple of days and they start mentally going south they have not suddenly developed schizophrenia, no need to do a psych consult. The short list would be to consider UTI, stroke, withdrawal....

[LV3677]

We use CIWA scale. We also use Precedex. It works very nicely for those patients. While a sedative, Precedex is not the same as other drugs that treat pain (i.e., those that cause respiratory depression) and anxiety. We worry more about cardiac issues when administering Precedex; HR, BP, AV blocks, etc.

Regarding intubation, it depends on the patient and what else is going on, but usually we are able to initiate Precedex on our withdrawing patients without intubation.

We usually turn to it when we realize that high doses of Ativan/Haldol are ineffective.

[emtb2rn, BSN, RN, EMT-B]

We use ciwa and if the score >10 an auto order for prn valium iv and ativan po is generated. Working well.

[Lev, MSN, RN, NP]

We use CIWA. If anything people undermedicate with Ativan per the CIWA protocol since 1/2 of the people who do CIWA ignore the last part of CIWA which involves asking patient for the current date, if they are sensitive to the light/sound, if they have a headache, if they have any hallucinations etc. People seem to focus on symptoms they can see such as vomiting, diaphoresis, tremor etc.

[mmc51264, BSN, MSN, RN]

We use CIWA and depending how bad it goes, they are on tele and sometimes end up on a step-down unit. We get a LOT alcoholics/polysubstance abuse. We take it seriously as do our docs so we try to keep them as stable as possible