phenobarbital for ETOH withdrawal

[freckles23]

So I am doing my capstone project for BSN on CIWA vs phenobarbital protocol for ETOH withdrawals. Since CIWA is symptom based and I find it to be a more subjective tool, alot of patients either become under or overmedicated on benzos. So I am writing about how phenobarbital should be used to prevent severe withdrawal symptoms and how the benefits outweigh CIWA.

Regarding pheno, can you administer this med on a general floor? I know it comes in PO, IV or IM. I work a cardiac floor and have many patients coming in for ETOH withdrawals and based on the CIWA, alot of the patients end up getting transferred to ICU. What happens once a patient is in ICU for ETOH withdrawal? Phenobarb IV is initiated? Is there a protocol/scale that you follow as your administering it? I am doing my research but need clarification on these questions that I cant seem to find.

What is your opinion?

[Jory, MSN, APRN, CNM]

If the patient is eating, there is no real reason to give it IV for prevention.

One of the reasons they get overmedicated...as much as folks don't want to admit it, is if a patient is simply being a PIA.

Most hospitals have a protocol they follow for which medication you use first, second, and so forth.

Phenobarbital is not the end all for withdrawal. It generally is not given if there are no signs or history of seizure activity.

[Corey Narry, MSN, RN, NP]

3 hours ago, freckles23 said:

Regarding pheno, can you administer this med on a general floor? I know it comes in PO, IV or IM. I work a cardiac floor and have many patients coming in for ETOH withdrawals and based on the CIWA, alot of the patients end up getting transferred to ICU. What happens once a patient is in ICU for ETOH withdrawal? Phenobarb IV is initiated? Is there a protocol/scale that you follow as your administering it? I am doing my research but need clarification on these questions that I cant seem to find.

What is your opinion?

I work for an institution that uses CIWA monitoring with the traditional benzodiazepine-based treatment algorithm. Our CIWA protocols are always initiated in the ICU after an ED admission if a patient is deemed a candidate for CIWA. The frequency of CIWA scoring and the amount of benzo's that may be required coupled with the risk of respiratory depression along with it led to a decision that the treatment is too labor-intensive for our floor nurses per our policy.

Although I'm more familiar with CIWA protocol, once in a while we do have new fellows who trained somewhere else and are advocating for a Phenobarbital based algorithm and swear by how this had better outcomes in their own experience. We've tried it on a few patients but I haven't seen enough cases of Phenobarbital algorithm for comparison to form my own opinion.

If you search online and based on what I know, initiation of Phenobarbital algorithm requires determination right in the ED when the patient presents with symptoms of withdrawal. The protocols typically ask for an IV loading dose if the patient meets criteria for Phenobarbital treatment with succeeding doses once patient is admitted. I doubt if your institution will allow such a loading dose in IV form in a cardiac floor but you'll have to check your hospital's policy on that.

Phenobarbital is also a respiratory depressant like benzo's so a heightened level of monitoring is required and your Cardiac floor may be unable to offer that. Most of what I can find on Phenobarbital algorithm are in the Emergency Medicine and Critical Care literature which leads me to believe that these are done in the ICU. However, there is a review article discussing Phenobarbital use in non-ICU settings here:

https://link.springer.com/article/10.1007/s40267-018-0523-1 (You'll have to pay to get the article).

There is a good explanation of the comparison of the two algorithms presented by an EM/Critical Care MD here that also goes over the dosing:

https://emcrit.org/pulmcrit/phenobarbital-monotherapy-for-alcohol-withdrawal-simplicity-and-power/

Finally, unlike our institution, OSU seems to protocolize both algorithms depending on patient presentation and inclusion criteria:

https://evidencebasedpractice.osumc.edu/Documents/Guidelines/AlcoholWithdrawal.pdf

[Night__Owl, BSN, RN]

I've used both, both are good, but I definitely prefer phenobarbital. You usually don't want any pt on the floor receiving the high doses of benzos, because of the respiratory risk involved. I've seen patients withdraw so hard that if they were awake at all they were a danger to self, so if they were dosed only to the point of not being combative, hallucinatory and self destructive, they were all but snowed. And snowed is very close to "not managing airway" so they needed to be watched closely, i.e. in ICU.

And you never know what someone's tolerance is, some people naturally only have a very narrow window between a treatment dose of a benzo vs a knockout dose. You don't wanna find that out when you do your hourly rounding and find your pt blue.

[VivaLasViejas, ASN, RN]

I'm all for detoxing people in the ICU. We used to do CIWA on the med/surg floor and it was a nightmare. I once took care of a guy who weighed around 400 pounds and was strong as an ox---he was in four-point leathers and still managed to march his bed across the room! I couldn't even let him out of one wrist restraint or he would have cleaned my clock (documenting my butt off, of course). I was giving him the max dose of Ativan every hour and it didn't even faze him. I called the doctor several times and on about the third call I got orders for Librium, which slowed the patient down a little but not enough. Finally after 12 hours of fighting with this guy, doc came in around 0630 and said "OK, he needs to be moved to the unit." Well DUH, that's what I'd been telling him all night. ?

[PeakRN]

Personally I prefer the phenobarb approach over benzos, I find it to be far more effective and the patient has a more stable level of therapy and taper compared to benzo based CIWA protocols.

I do find that there is a significant amount of fear from many medical and nursing providers about giving a barbiturate, particularly that we cannot reverse it. The reality is that we wouldn't be giving romazicon to a patient receiving benzos for ETOH withdraw anyway due to the risk of seizures.

I highly doubt that any floor would administer phenobarb. That being said I don't think that it is really any more dangerous than any other CIWA protocol medication with given by a competent nurse.

[TriciaJ, RN]

I've cared for ETOH detox patients in several psych units and a jail, before CIWA was invented. The MO was to treat elevations in vital signs with Librium and not wait for the tremors and diaphoresis, if they weren't already present.

I disliked using CIWA (later on med/surg floor) because the algorithm didn't take vital signs into account, which will begin to elevate before the other symptoms present themselves.

Regardless of where I was or what protocol I was using, you can bet I checked the patient a lot oftener than every hour.

[NurseCard, ADN]

6 hours ago, VivaLasViejas said:

I'm all for detoxing people in the ICU. We used to do CIWA on the med/surg floor and it was a nightmare. I once took care of a guy who weighed around 400 pounds and was strong as an ox---he was in four-point leathers and still managed to march his bed across the room! I couldn't even let him out of one wrist restraint or he would have cleaned my clock (documenting my butt off, of course). I was giving him the max dose of Ativan every hour and it didn't even faze him. I called the doctor several times and on about the third call I got orders for Librium, which slowed the patient down a little but not enough. Finally after 12 hours of fighting with this guy, doc came in around 0630 and said "OK, he needs to be moved to the unit." Well DUH, that's what I'd been telling him all night. ?

You know why this is scary?

This is scary, because I work in this itty-bitty hospital with one Med Surge unit, no ICU... and at night, about 8-9 people in the whole building.

We do CIWA protocol and admit patients for alcohol withdrawal.

Yeah.

Oh, and I didn't mention... little to no Crisis Intervention training, and little to no training on the emergency use of restraints. We do have a policy and we have been educated on it.. but as far as physically restraining someone... we've had a little bit of training, but not enough IMO.

[NurseCard, ADN]

4 hours ago, TriciaJ said:

I've cared for ETOH detox patients in several psych units and a jail, before CIWA was invented. The MO was to treat elevations in vital signs with Librium and not wait for the tremors and diaphoresis, if they weren't already present.

I disliked using CIWA (later on med/surg floor) because the algorithm didn't take vital signs into account, which will begin to elevate before the other symptoms present themselves.

Regardless of where I was or what protocol I was using, you can bet I checked the patient a lot oftener than every hour.

So true. So many of us find ourselves asking "Hey! Why is that dude's heart rate 130?"... because he's withdrawing, that's why.

[VivaLasViejas, ASN, RN]

20 hours ago, NurseCard said:

You know why this is scary?

This is scary, because I work in this itty-bitty hospital with one Med Surge unit, no ICU... and at night, about 8-9 people in the whole building.

We do CIWA protocol and admit patients for alcohol withdrawal.

Yeah.

Oh, and I didn't mention... little to no Crisis Intervention training, and little to no training on the emergency use of restraints. We do have a policy and we have been educated on it.. but as far as physically restraining someone... we've had a little bit of training, but not enough IMO.

That's just plain crazy. Someone is going to get hurt, whether it's a patient or a nurse, and then watch all the finger-pointing. Sounds like the hospital needs to develop some trainings and better policies. Better yet, they ought to send CIWA patients to other facilities, even if those hospitals are further away. Sheesh!

[Jedrnurse, BSN, RN]

On 3/5/2019 at 4:45 PM, Night__Owl said:

I've used both, both are good, but I definitely prefer phenobarbital. You usually don't want any pt on the floor receiving the high doses of benzos, because of the respiratory risk involved. I've seen patients withdraw so hard that if they were awake at all they were a danger to self, so if they were dosed only to the point of not being combative, hallucinatory and self destructive, they were all but snowed. And snowed is very close to "not managing airway" so they needed to be watched closely, i.e. in ICU.

And you never know what someone's tolerance is, some people naturally only have a very narrow window between a treatment dose of a benzo vs a knockout dose. You don't wanna find that out when you do your hourly rounding and find your pt blue.

I've always been taught that the risk of respiratory depression is greater with barbituates than with benzos. Is this not the case?

[freckles23]

On 3/5/2019 at 1:34 PM, juan de la cruz said:

I work for an institution that uses CIWA monitoring with the traditional benzodiazepine-based treatment algorithm. Our CIWA protocols are always initiated in the ICU after an ED admission if a patient is deemed a candidate for CIWA. The frequency of CIWA scoring and the amount of benzo's that may be required coupled with the risk of respiratory depression along with it led to a decision that the treatment is too labor-intensive for our floor nurses per our policy.

Although I'm more familiar with CIWA protocol, once in a while we do have new fellows who trained somewhere else and are advocating for a Phenobarbital based algorithm and swear by how this had better outcomes in their own experience. We've tried it on a few patients but I haven't seen enough cases of Phenobarbital algorithm for comparison to form my own opinion.

If you search online and based on what I know, initiation of Phenobarbital algorithm requires determination right in the ED when the patient presents with symptoms of withdrawal. The protocols typically ask for an IV loading dose if the patient meets criteria for Phenobarbital treatment with succeeding doses once patient is admitted. I doubt if your institution will allow such a loading dose in IV form in a cardiac floor but you'll have to check your hospital's policy on that.

Phenobarbital is also a respiratory depressant like benzo's so a heightened level of monitoring is required and your Cardiac floor may be unable to offer that. Most of what I can find on Phenobarbital algorithm are in the Emergency Medicine and Critical Care literature which leads me to believe that these are done in the ICU. However, there is a review article discussing Phenobarbital use in non-ICU settings here:

https://link.springer.com/article/10.1007/s40267-018-0523-1 (You'll have to pay to get the article).

There is a good explanation of the comparison of the two algorithms presented by an EM/Critical Care MD here that also goes over the dosing:

https://emcrit.org/pulmcrit/phenobarbital-monotherapy-for-alcohol-withdrawal-simplicity-and-power/

Finally, unlike our institution, OSU seems to protocolize both algorithms depending on patient presentation and inclusion criteria:

https://evidencebasedpractice.osumc.edu/Documents/Guidelines/AlcoholWithdrawal.pdf

These articles are great! Lots of information I was attempting to look for. Very helpful!