How are you assessing alcohol withdrawal?

Nurses General Nursing

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  1. Is your hospital using CIWA?

    • 22
      Yes
    • 1
      No

23 members have participated

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! :)

We use Ativan.....and Precedex. Hehe

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I've dealth with a crapton of drunks, in ICU, Med/Surg, and now in Obs almost from coast to coast. (I'm one state away from Cali, otherwise it would be coast to coast.)

I like mSAS better than CIWA because it is more comprehensive. Either way, I have had bad experiences with fellow nurses not following the protocol. I will knock a patient out as long as they are breathing, but a lot of nurses are scared to give adequate benzo coverage.

Ativan/librium combo works best in the acute phase on a Med/Surg level, in my experience. Precedex works OK, but when I was in ICU it had some sort of set end time, like 24 hours, per policy. I don't remember now, that was during my 3 month stint in a MICU almost three years ago.

I love an Ativan drip with PRN IV ativan with scheduled Haldol. I had a SEVERE detoxer in a neuro ICU and it knocked him down to where he wasn't climbing the walls but could still wake up enough to use a urinal. He was on an 8mg/hr Ativan drip with up to 4mg IV push Q1H with 5mg Haldol Q4 or Q6 ish. Not intubated. I had the most fun with that guy. He was a funny person at baseline and he was hallucinating in a happy way.

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Specializes in Neuro ICU and Med Surg.

We use CIWA and many get under medicated with that. It is too subjective, and no one is asking about light sensitivity, hallucinations, etc. Many times I have had to take a patient to ICU or IMC due to escalating scores.

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We use CIWAs with VS. Treat with ativan, librium, and haldol/zyprexa. We prefer our actively detoxing pt's remain mildly sedated. Our docs do as well. I take the CIWA very seriously and will make the pt do math, will feel their hands for sweat and tremors. Some pts game the scale for extra ativan, but I'm not about to risk a pt going into DTs just b/c one pt before fudged his/her answers.

We can't do precedex/ativan gtt on my floor, so a pt needing that gets sent down the hall to CCU.

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Specializes in Public Health, TB.

I recently read a case study on Medscape where they used gabapentin instead of a benzo to flood the GABA receptors. Has any one used this?

BTW, we use CIWA with diazepam for healthy livers, lorazepam for unhealthy and elderly. And always roundup if there is any question at all about the score.

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Since I've never heard of CIWA, I'm guessing we don't use it. We used to use Librium a lot more than we do now. Now, it's mostly Ativan, on a taper. We do give Librium PRN to patients who don't have a problem taking PO meds. We do occasionally have a doctor who will order wine or beer for the patient. I wish more doctors did it.

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Specializes in Cardiac, Transplant, Intermediate Care.

At my facility, we use CIWA and s/s lorezepam and s/s diazepam.

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Specializes in ED, ICU, PSYCH, PP, CEN.

We use the CIWA scale. The biggest problem we see is a lot of nurses don't follow up appropriately. The scale says how much to give for numerical rating above 8, and so on, and to assess after 1 hour. You then give more medication based on that score. As the numbers go down on the scale you give less medication less frequently. I do think fear of overdosing is a big concern. Almost all our detoxers end up in ICU because the med/surg nurses don't have time to care for these patients.

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Specializes in OB.
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....

Ah yes, I remember well working on a med/surg unit as a new grad, taking care of a vascular surgical patient who had had a AAA repair. Right before I left for the night I noticed he was acting strangely, but I couldn't put my finger on what was going on.

When I came back in the morning the night nurse told me his roommate had come into the hall in the middle of the night and said "Nurse, my roommate is taking a dump in the garbage can." After some questioning, she had a lightbulb moment, called his family, and it turned out yes, he generally drank 10 beers per night, so this might be withdrawal. He was in the stepdown unit on Ativan by the time I came in. We didn't really get alcohol withdrawal patients otherwise, so I don't believe we used any scale like CIWA, but I'm assuming there was one for the medical, psych, and ED units where those patients mostly stayed.

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Specializes in critical care.
Almost all our detoxers end up in ICU because the med/surg nurses don't have time to care for these patients.

This is such a HUGE frustration of mine. I feel those nurse's pain. Med/surg is NOT appropriate for detox. My step down unit, with us taking 4-5 patients, is not either. We don't have a psych unit. We don't have a detox unit. We have med/surg and step down. This will NEVER be appropriate for detoxing patients and for the life of me, I can't figure out why we aren't turfing these people to appropriate levels of care at a facility that can handle this and are TRAINED for this.

You know the BEST way to get nurses who aren't afraid of benzos? GET THEM ON A DETOX AND/OR PSYCH FLOOR. We don't even have psych on CONSULT let alone a whole unit. We need to stop admitting these patients and giving inadequate care/treatment/referrals.

We need to be turfing our complicated suicides, too. My docs have no clue how to handle a PMH of schizophrenia or bipolar in a suicide attempt. The first thing they do is stop the psych meds. BUT WHY?!?!?!? We keep the patients for the standard few days or longer until stable, and by then, they'll be all kinds of messed up.

Sorry for the rant, but I'm really so frustrated with all of this. We get good at our specialties. I do cardiac, neuro, respiratory, usually. Psych is infrequently, and we're not awesome at it. These patients NEED better than we can give them.

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Specializes in Family Nurse Practitioner.
This is such a HUGE frustration of mine. I feel those nurse's pain. Med/surg is NOT appropriate for detox. My step down unit, with us taking 4-5 patients, is not either. We don't have a psych unit. We don't have a detox unit. We have med/surg and step down. This will NEVER be appropriate for detoxing patients and for the life of me, I can't figure out why we aren't turfing these people to appropriate levels of care at a facility that can handle this and are TRAINED for this.

You know the BEST way to get nurses who aren't afraid of benzos? GET THEM ON A DETOX AND/OR PSYCH FLOOR. We don't even have psych on CONSULT let alone a whole unit. We need to stop admitting these patients and giving inadequate care/treatment/referrals.

We need to be turfing our complicated suicides, too. My docs have no clue how to handle a PMH of schizophrenia or bipolar in a suicide attempt. The first thing they do is stop the psych meds. BUT WHY?!?!?!? We keep the patients for the standard few days or longer until stable, and by then, they'll be all kinds of messed up.

Sorry for the rant, but I'm really so frustrated with all of this. We get good at our specialties. I do cardiac, neuro, respiratory, usually. Psych is infrequently, and we're not awesome at it. These patients NEED better than we can give them.

Psych units do not take withdrawal patients because they are acutely ill. Where I used to work, the m/s floors could only take people who needed withdrawal assessment scales q4h. If any more frequent than that, they went to intermediate care (ratio 1:3-4). We didn't use CIWA there.

Many of the psych meds can actually cause suicidal ideation. The only issue I can think of from stopping psych meds is withdrawing from the meds themselves. However, you can treat the symptoms with ativan, give them meds to help them sleep, and give them meds for diarrhea.

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I'm on a M/S unit and we take q1hr CIWA pts. We don't turf unless their CIWA scores are above 28 or they have respiratory depression. We try very hard to make a nurse w a q1hr pt have 3:1, but occasionally they get sunk w 4:1. In that case we all pitch in so that nurse can stay on top of the detoxer. I take mild offense to the assertion that M/S is unable to provide adequate care. It isn't us as nurses, it is our staffing shortage, thank you.

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