| Abstract: | In an article published April 27 in JAMA Internal Medicine, “Challenges in Prediction, Diagnosis, and Treatment of Alcohol Withdrawal in Medically Ill Hospitalized Patients: A Teachable Moment,” Thomas D. Brothers, M.D., and Paxton Bach, M.D., write about the case of a man admitted to the hospital for planned bowel resection. The patient said he drank 8 to 10 ounces of whiskey a day but that his last drink was three days prior to admission. There were no symptoms of alcohol withdrawal during the first week. But he required an urgent reoperation on day 6, and on day 9, he became disoriented and inattentive, with large intra‐abdominal abscesses. On day 13, he became more agitated and confused, and clinicians implemented withdrawal treatment protocol using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale. He scored high — anxiety, agitation, hallucinations and disorientation — and was given 10 mg of diazepam, with improvement in his symptoms requiring no further medication. However, the next day he was even more confused and agitated, again scoring high. After another 10‐mg dose of diazepam, he became sedated and had to be transferred to a monitored unit. “In this case, poor understanding of the natural history of alcohol withdrawal led the inpatient team to misdiagnose alcohol withdrawal and inappropriately implement a CIWA protocol,” the researchers wrote. “Alcohol withdrawal symptoms generally begin 6 to 12 hours after the last drink and peak at 24 to 72 hours. Although withdrawal‐related seizures can occur at any time during this course, delirium tremens tends to occur three to seven days after the last drink, and only after progressing through more mild symptoms. For this patient, acute onset of severe alcohol withdrawal more than 1 week after the last drink would be highly unusual, especially without first demonstrating mild withdrawal.” Patients do become agitated under certain medical conditions, including pain and intubation. In this case, the patient was unnecessarily given high doses of benzodiazepines. He was not in alcohol withdrawal. |
