Alcohol withdrawal and delirium tremens in the critically ill: a systematic review and commentary

• Published in: Intensive care medicine Vol. 39; no. 1; pp. 16 - 30
• Main Authors: Awissi, Don-Kelena, Lebrun, Genevieve, Coursin, Douglas B., Riker, Richard R., Skrobik, Yoanna
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer-Verlag 2013; Springer; Springer Nature B.V
• Subjects: Alcohol use; Alcohol withdrawal; Alcohol Withdrawal Delirium - diagnosis; Alcohol Withdrawal Delirium - therapy; Alcoholism; Anesthesiology; Care and treatment; Critical care; Critical Care Medicine; Critical Illness; Delirium; Delirium tremens; Disease prevention; Emergency Medicine; Ethanol - adverse effects; Evidence-based medicine; Hospital patients; Humans; Intensive; Intensive care; Intensive Care Units; Medicine; Medicine & Public Health; Pain Medicine; Pediatrics; Pneumology/Respiratory System; Practice guidelines (Medicine); Review; Risk Factors; Substance abuse; Substance Withdrawal Syndrome - diagnosis; Substance Withdrawal Syndrome - therapy; Systematic review; United Kingdom; Canada; United States > US; Montreal Quebec Canada; Sedatives; Delirium; Intensive care; Withdrawal; Critical care; Alcohol; Alcohol withdrawal syndrome; Delirium tremens
• ISSN: 0342-4642; 1432-1238
• DOI: 10.1007/s00134-012-2758-y

Introduction
Alcohol withdrawal is common among intensive care unit (ICU) patients, but no current practice guidelines exist. We reviewed published manuscripts for prevalence, risk factors, screening tools, prophylactic and treatment strategies, and outcomes for alcohol withdrawal syndrome (AWS) and delirium tremens (DT) in the critically ill.
Methods
The following databases: PubMed, MEDLINE, Embase, Cochrane Database of Systematic Reviews and Central Register of Controlled Trials, CINAHL, Scopus, Web of Knowledge, pain, anxiety and delirium (PAD) Guidelines REFWORKS, International Pharmaceutical Abstracts and references for published papers were searched. Publications with high or moderate Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Oxford levels of evidence were included.
Results
Reported AWS rates range from <1 % in ‘all ICU comers’ to 60 % in highly selected alcohol-dependent ICU patients. Alcohol dependence and a history of withdrawal are significant risk factors for AWS occurrence. No screening tools for withdrawal have been validated in the ICU. The benefit of alcohol withdrawal prophylaxis is unproven, and proposed regimens appear equivalent. Early and aggressive titration of medication guided by symptoms is the only feature associated with improved treatment outcome.
Conclusions
Treatment of AWS is associated with higher ICU complication rates and resource utilization. The optimal means of identification, prevention and treatment of AWS in order to establish evidence-based guidelines remain to be determined.