Comprehensive Overview of CIWA-Ar Scale for Alcohol Withdrawal Management

This article provides detailed information on the Clinical Institutes Withdrawal Assessment Scale for Alcohol (CIWA-Ar), focusing on its utilization in managing alcohol withdrawal symptoms. It covers learning objectives, signs and symptoms of alcohol withdrawal, complications, timelines, and the benefits of CIWA scoring over standing regimens. The content includes images, a video vignette, and references for further exploration, offering a holistic understanding of symptom-triggered therapy for alcohol withdrawal.

• Alcohol Withdrawal
• CIWA-Ar Scale
• Symptom-Triggered Therapy
• Alcohol Withdrawal Management
• Benzodiazepine Reduction

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1. CIWA Co-Teaching Session September 11, 2019 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

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

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

5. 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

6. 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

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

8. 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

9. 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

10. 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

11. 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

12. ITs TIme for IT s TIme for some some Vignettes! Vignettes!

13. Case 1 Patient admitted for alcohol withdrawal Initial AUDIT-C score of 5 ordered for alcohol withdrawal order set including CIWA every 4 hours. First two CIWA scores: 4 and 5 Next two CIWA scores: 12 and 15 (given 2 mg of lorazepam each time) It is now 4 hours since last dose of lorazepam, CIWA is 15 What are the appropriate next steps? What if the CIWA score was 17?

14. Case 2 A Navajo-speaking male was admitted with an Audit-C score of 5. The order "CIWA per policy" is placed through the Alcohol Withdrawal Order Set. The patient's assessment includes: mild nausea mild-moderate tremor with hands extended moderate anxiety normal activity What is the patient s CIWA score? What are your next steps? sweaty palms oriented x7 mild-moderate itch no auditory/visual disturbances mild headache

15. An Alternative Vignette Thank You!!! Thank You!!! https://www.youtube.com/watch?v=tKTh05lyvPI

16. Additional slides

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

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