Comprehensive Overview of CIWA-Ar Scale for Alcohol Withdrawal Management

 
CIWA Co-Teaching
Session
 
September 11, 2019
Holli Murray
Bill Martin-Doyle
 
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
 
Video Vignette - Score The CIWA Yourself!
 
 
CIWA Scoring
 
https://www.mdcalc.com/ciwa-ar-alcohol-withdrawal
 
Nausea/vomiting
Headache
Anxiety
Tremor
Diaphoresis
Agitation
Restlessness
 
Signs and Symptoms of Alcohol Withdrawal
 
Change in VS: Increased BP,
HR, RR
Confusion
Delirium
Hallucinations
Seizures
Delirium Tremens
 
Modified from BWH Psychiatric Resource Nursing Service “BWH Alcohol Withdrawal: Risk Assessment and Treatment”
 
~80% mild-to-
moderate
~20% severe /
complicated:
Hallucinations
Seizures
Delirium Tremens
 
Complications of Alcohol Withdrawal
 
Saitz et al. Med Clin North Am. 1997;81(4):881
 
Timeline of Alcohol Withdrawal
 
Stern TA, et al. Massachusetts General Hospital - Comprehensive Clinical Psychiatry, Second Edition. Elsevier 2016
 
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
 
What is the CIWA-Ar Scale?
 
CIWA Scoring Reduces Duration of Medication Administration and
Benzodiazepine Dosing
 
P<0.001
 
P<0.001
 
P<0.001
 
P<0.001
 
Mg
 
Hours
 
N=101
 
N=117
 
N=101
 
N=117
 
CIWA-triggered dosing
 
Standing / fixed-dose regimen
 
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
History of severe withdrawal
(delirium tremens, withdrawal seizure)
Patient already in severe alcohol withdrawal
(presenting with DTs and/or seizures)
 
When You Should Consider Standing Regimen
Patient unable to communicate
Comorbidities Making CIWA Scoring Difficult
CIWA ≥ 16
 
IT’s Time for
some
Vignettes!
 
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?
 
Case 1
 
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
sweaty palms
oriented x7
mild-moderate itch
no auditory/visual disturbances
mild headache
 
Case 2
 
What is the patient’s CIWA score?
What are your next steps?
 
https://www.youtube.com/watch?v=tKTh05lyvPI
 
An Alternative Vignette
 
Thank You!!!
 
Additional slides
 
CIWA-Ar Outcomes vs Symptom Triggered
 
N=51
 
N=50
 
p<0.001
 
p<0.001
 
CIWA-Ar Outcomes vs Symptom Triggered
 
p<0.001
 
p<0.001
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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.


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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

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