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People hospitalized with alcohol withdrawal syndrome (AWS) and treated with continuously infused high dose sedatives may not need to be intubated, as long as they are monitored for signs of worsening gas exchange and aspiration, suggests a single-center retrospective study.
Standard practice is to treat AWS patients with sedating drugs in order to mitigate the catecholamine storm and agitation. Even at low doses, these medications can cause cardiorespiratory instability and the issue of when to secure the airways of these patients has remained a clinical question.
In their study, (Ann Am Thorac Soc. 2016 Feb 1. 13[2],162-4) Dr. Robert Stewart of Texas A&M University, College Station, and his colleagues described the outcomes of 188 patients with AWS given lorazepam as a continuous infusion up to 1.2 mg per hour with intermittent boluses of 1-2 mg when their Clinical Institute Withdrawal Assessment Score was greater than 6.
Transfer to the ICU was initiated only as clinically indicated or when higher doses of continuous hypnotics were needed. For instance, 170 of the patients also received midazolam, all but 2 by continuous intravenous infusion (median total dose, 527 mg; all administered in ICU); 19 received propofol (median total dose, 6,000 mg); and 19 received dexmedetomidine (median total dose, 1,075 mg).
All patients were monitored by continuous pulse oximetry and nasal capnography and were only intubated when gas exchange worsened or macro-aspiration was observed.
No explicit criteria mandated intubation and clinicians, most of whom were ICU residents, were required to determine ad hoc the degree of gas exchange failure or apparent aspiration that warranted intubation.
Overall, 36 (19%) of the 188 patients required intubation. These patients tended to have a higher APACHE II score (greater than 10) and to receive substantially more benzodiazepine than non-intubated patients (761 mg of lorazepam equivalent vs 229 mg; P less than 0.0001).
Intubated patients also had longer hospital lengths of stays (median, 14.7 vs. 6.0 days; P less than 0.0001) and more pneumonias (58.3% vs. 5.9%; P less than 0.0001). One patient died, and had been intubated.
“Our study adds to those cited previously suggesting that high doses of sedatives can be given without mandatory intubation, provided patients are closely monitored,” the researchers said. “Whether this practice is safer and more effective than pre-emptive intubation for such patients remains an open question.”
The researchers declared no relevant conflicts of interest.
Many clinicians feel comfortable administering benzodiazepines by intravenous bolus to patients without high levels of monitoring, yet will use continuous infusions only in more monitored settings such as an ICU in patients with “protected airways” via intubation and mechanical ventilation. The current study forces critical care clinicians to question the status quo.
Are we really helping patients by racing to intubate those we deem in need of continuous sedative infusions for AWS for fear of what might happen, when we know intubation and mechanical ventilation have their own risks?
Mechanical ventilation can be associated with pneumonia, weakness, and delirium. Further, patients with alcohol withdrawal syndrome who receive invasive mechanical ventilation are more likely to have poor outcomes.
The current study illustrated the use of low-dose continuous benzodiazepines (lorazepam) on the general hospital wards and deferred intubation. Nevertheless, there were limitations to the study stemming from its design as a retrospective analysis of a single center’s experience. Also, it was not clear how safe or effective a similar protocol of continuous benzodiazepine infusions coupled with delayed intubation might be in a setting in which practitioners are less comfortable with the complications of AWS and its treatments and have less access to continuous end-tidal carbon dioxide measurements.
Dr. Hayley B. Gershengorn is with the Albert Einstein College of Medicine, New York. She made her remarks in an editorial (Ann Am Thorac Soc. 2016 Feb 1. 13[2], 162–4) that accompanied the study.
Many clinicians feel comfortable administering benzodiazepines by intravenous bolus to patients without high levels of monitoring, yet will use continuous infusions only in more monitored settings such as an ICU in patients with “protected airways” via intubation and mechanical ventilation. The current study forces critical care clinicians to question the status quo.
Are we really helping patients by racing to intubate those we deem in need of continuous sedative infusions for AWS for fear of what might happen, when we know intubation and mechanical ventilation have their own risks?
Mechanical ventilation can be associated with pneumonia, weakness, and delirium. Further, patients with alcohol withdrawal syndrome who receive invasive mechanical ventilation are more likely to have poor outcomes.
The current study illustrated the use of low-dose continuous benzodiazepines (lorazepam) on the general hospital wards and deferred intubation. Nevertheless, there were limitations to the study stemming from its design as a retrospective analysis of a single center’s experience. Also, it was not clear how safe or effective a similar protocol of continuous benzodiazepine infusions coupled with delayed intubation might be in a setting in which practitioners are less comfortable with the complications of AWS and its treatments and have less access to continuous end-tidal carbon dioxide measurements.
Dr. Hayley B. Gershengorn is with the Albert Einstein College of Medicine, New York. She made her remarks in an editorial (Ann Am Thorac Soc. 2016 Feb 1. 13[2], 162–4) that accompanied the study.
Many clinicians feel comfortable administering benzodiazepines by intravenous bolus to patients without high levels of monitoring, yet will use continuous infusions only in more monitored settings such as an ICU in patients with “protected airways” via intubation and mechanical ventilation. The current study forces critical care clinicians to question the status quo.
Are we really helping patients by racing to intubate those we deem in need of continuous sedative infusions for AWS for fear of what might happen, when we know intubation and mechanical ventilation have their own risks?
Mechanical ventilation can be associated with pneumonia, weakness, and delirium. Further, patients with alcohol withdrawal syndrome who receive invasive mechanical ventilation are more likely to have poor outcomes.
The current study illustrated the use of low-dose continuous benzodiazepines (lorazepam) on the general hospital wards and deferred intubation. Nevertheless, there were limitations to the study stemming from its design as a retrospective analysis of a single center’s experience. Also, it was not clear how safe or effective a similar protocol of continuous benzodiazepine infusions coupled with delayed intubation might be in a setting in which practitioners are less comfortable with the complications of AWS and its treatments and have less access to continuous end-tidal carbon dioxide measurements.
Dr. Hayley B. Gershengorn is with the Albert Einstein College of Medicine, New York. She made her remarks in an editorial (Ann Am Thorac Soc. 2016 Feb 1. 13[2], 162–4) that accompanied the study.
People hospitalized with alcohol withdrawal syndrome (AWS) and treated with continuously infused high dose sedatives may not need to be intubated, as long as they are monitored for signs of worsening gas exchange and aspiration, suggests a single-center retrospective study.
Standard practice is to treat AWS patients with sedating drugs in order to mitigate the catecholamine storm and agitation. Even at low doses, these medications can cause cardiorespiratory instability and the issue of when to secure the airways of these patients has remained a clinical question.
In their study, (Ann Am Thorac Soc. 2016 Feb 1. 13[2],162-4) Dr. Robert Stewart of Texas A&M University, College Station, and his colleagues described the outcomes of 188 patients with AWS given lorazepam as a continuous infusion up to 1.2 mg per hour with intermittent boluses of 1-2 mg when their Clinical Institute Withdrawal Assessment Score was greater than 6.
Transfer to the ICU was initiated only as clinically indicated or when higher doses of continuous hypnotics were needed. For instance, 170 of the patients also received midazolam, all but 2 by continuous intravenous infusion (median total dose, 527 mg; all administered in ICU); 19 received propofol (median total dose, 6,000 mg); and 19 received dexmedetomidine (median total dose, 1,075 mg).
All patients were monitored by continuous pulse oximetry and nasal capnography and were only intubated when gas exchange worsened or macro-aspiration was observed.
No explicit criteria mandated intubation and clinicians, most of whom were ICU residents, were required to determine ad hoc the degree of gas exchange failure or apparent aspiration that warranted intubation.
Overall, 36 (19%) of the 188 patients required intubation. These patients tended to have a higher APACHE II score (greater than 10) and to receive substantially more benzodiazepine than non-intubated patients (761 mg of lorazepam equivalent vs 229 mg; P less than 0.0001).
Intubated patients also had longer hospital lengths of stays (median, 14.7 vs. 6.0 days; P less than 0.0001) and more pneumonias (58.3% vs. 5.9%; P less than 0.0001). One patient died, and had been intubated.
“Our study adds to those cited previously suggesting that high doses of sedatives can be given without mandatory intubation, provided patients are closely monitored,” the researchers said. “Whether this practice is safer and more effective than pre-emptive intubation for such patients remains an open question.”
The researchers declared no relevant conflicts of interest.
People hospitalized with alcohol withdrawal syndrome (AWS) and treated with continuously infused high dose sedatives may not need to be intubated, as long as they are monitored for signs of worsening gas exchange and aspiration, suggests a single-center retrospective study.
Standard practice is to treat AWS patients with sedating drugs in order to mitigate the catecholamine storm and agitation. Even at low doses, these medications can cause cardiorespiratory instability and the issue of when to secure the airways of these patients has remained a clinical question.
In their study, (Ann Am Thorac Soc. 2016 Feb 1. 13[2],162-4) Dr. Robert Stewart of Texas A&M University, College Station, and his colleagues described the outcomes of 188 patients with AWS given lorazepam as a continuous infusion up to 1.2 mg per hour with intermittent boluses of 1-2 mg when their Clinical Institute Withdrawal Assessment Score was greater than 6.
Transfer to the ICU was initiated only as clinically indicated or when higher doses of continuous hypnotics were needed. For instance, 170 of the patients also received midazolam, all but 2 by continuous intravenous infusion (median total dose, 527 mg; all administered in ICU); 19 received propofol (median total dose, 6,000 mg); and 19 received dexmedetomidine (median total dose, 1,075 mg).
All patients were monitored by continuous pulse oximetry and nasal capnography and were only intubated when gas exchange worsened or macro-aspiration was observed.
No explicit criteria mandated intubation and clinicians, most of whom were ICU residents, were required to determine ad hoc the degree of gas exchange failure or apparent aspiration that warranted intubation.
Overall, 36 (19%) of the 188 patients required intubation. These patients tended to have a higher APACHE II score (greater than 10) and to receive substantially more benzodiazepine than non-intubated patients (761 mg of lorazepam equivalent vs 229 mg; P less than 0.0001).
Intubated patients also had longer hospital lengths of stays (median, 14.7 vs. 6.0 days; P less than 0.0001) and more pneumonias (58.3% vs. 5.9%; P less than 0.0001). One patient died, and had been intubated.
“Our study adds to those cited previously suggesting that high doses of sedatives can be given without mandatory intubation, provided patients are closely monitored,” the researchers said. “Whether this practice is safer and more effective than pre-emptive intubation for such patients remains an open question.”
The researchers declared no relevant conflicts of interest.
FROM ANNALS OF THE AMERICAN THORACIC SOCIETY
Key clinical point: Pre-emptive intubation may not be necessary in patients with alcohol withdrawal syndrome who are treated in hospital with continuously infused high dose sedatives.
Major finding: Overall, 36 (19%) of the 188 patients involved in the study required intubation.
Data source: An observational single center retrospective study of 188 consecutive patients hospitalized with alcohol withdrawal syndrome.
Disclosures: No relevant conflicts of interest were declared.