Alcohol Withdrawal Management: CIWA Co-Teaching Session Highlights

Explore key aspects of managing alcohol withdrawal through the CIWA scale in a co-teaching session. Learning objectives include recognizing withdrawal symptoms, determining appropriate protocol application, and utilizing the CIWA scale for symptom-triggered management. Dive into case scenarios and vignettes to enhance understanding, with insights on complications of alcohol withdrawal provided.

• Alcohol withdrawal
• CIWA scale
• Co-teaching session
• Symptoms
• Management

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1. CIWA Co-Teaching Session February 3, 2020 Holli Murray Bill Martin-Doyle

2. Learning Objectives 1. Describe the signs and symptoms of alcohol withdrawal 2. Determine who is appropriate for a CIWA-based protocol as compared to a standing regimen 3. Utilize the CIWA scale to guide symptom-triggered management of alcohol withdrawal

4. Video Vignette - Score The CIWA Yourself! https://www.youtube.com/watch?v=NUKigZjcGy4

5. CIWA Scoring https://www.mdcalc.com/ciwa-ar-alcohol-withdrawal

6. Vignettes! Vignettes!

7. Case 1 A 45 year old male is admitted for alcohol withdrawal and ordered for CIWA per protocol every 4 hours His CIWA scores following admission are: 8:00 12:00 16:00 20:00 22:00 4 5 12 15 17 2mg lorazepam were given for scores 12 and 15. It is now 22:00. Do you continue the CIWA? If the answer is no - stand up!

8. Case 2 A 70 year old patient with alcohol dependence is admitted for Community Acquired Pneumonia Patient was initially hypotensive but is now stabilized PMH includes severe Parkinson s Disease. Do you put this patient on CIWA? If the answer is no - stand up!

9. Case 3 A 25 year old American Sign Language-speaking deaf patient with alcohol use disorder and no other PMH is admitted for alcohol withdrawal Do you put this patient on CIWA? If the answer is no - stand up!

10. ITs TIme for IT s TIme for some SLIDES! some SLIDES!

11. Complications of Alcohol Withdrawal ~80% mild-to- moderate ~20% severe / complicated: Hallucinations Seizures Delirium Tremens Saitz et al. Med Clin North Am. 1997;81(4):881

12. Timeline of Alcohol Withdrawal Stern TA, et al. Massachusetts General Hospital - Comprehensive Clinical Psychiatry, Second Edition. Elsevier 2016

13. CIWA Scoring Reduces Duration of Medication Administration and Benzodiazepine Dosing Duration of medication administration / admission (hours) Total Benzodiazepine Dosing (mg) 500 P<0.001 P<0.001 P<0.001 P<0.001 80.0 425.0 450 68.0 70.0 400 62.7 350 60.0 300 50.0 Hours 231.4 Mg 250 40.0 200 30.0 150 100.0 20.0 100 20.0 37.5 50 9.0 10.0 0 0.0 JAMA 1994 (Chlordiazepoxide) N=101 Arch Int Med 2002 (Oxazepam) N=117 JAMA 1994 N=101 Arch Int Med 2002 N=117 CIWA-triggered dosing Standing / fixed-dose regimen

14. Questions? Questions?

15. Thank You!!! Thank You!!!

16. Additional slides

17. Signs and Symptoms of Alcohol Withdrawal Nausea/vomiting Change in VS: Increased BP, Headache HR, RR Anxiety Confusion Tremor Delirium Diaphoresis Hallucinations Agitation Seizures Restlessness Delirium Tremens Modified from BWH Psychiatric Resource Nursing Service BWH Alcohol Withdrawal: Risk Assessment and Treatment

18. When You Should Consider Standing Regimen History of severe withdrawal (delirium tremens, withdrawal seizure) Patient already in severe alcohol withdrawal (presenting with DTs and/or seizures) Patient unable to communicate Comorbidities Making CIWA Scoring Difficult CIWA 16

19. CIWA-Ar Outcomes vs Symptom Triggered N=51 N=50 p<0.001 p<0.001

20. CIWA-Ar Outcomes vs Symptom Triggered p<0.001 p<0.001

21. Where to find Epic Alcohol Withdrawal Orders 1 Order sets: alcohol withdrawal 2 Ativan per CIWA: standard vs low dose; IV vs PO 3 Thiamine, MVI, Folate

22. What is the CIWA-Ar Scale? Clinical Institutes Withdrawal Assessment Scale for Alcohol (CIWA-Ar) Symptom-triggered therapy Studied primarily in moderate severity withdrawal (i.e., no seizures, DTs, able to take PO, no severe comorbidities ) Ten areas to assess and score (0-7 each), total score of 67 Mild: 0-8 Moderate: 9-15 Severe: > 16, higher risk seizure/DTs Benefits compared to standing regimen: Reduced total amount of benzodiazepines administered Shorter duration of treatment