Alcohol Withdrawal Guideline

This guideline is the Institutional Guideline for all of UK Healthcare and is based upon: 1)  liberal screening using CAGE followed by 2) regular CIWA scoring every 4 hours for 24 hours (http://www.mdcalc.com/ciwa-ar-for-alcohol-withdrawal/). See nursing and physician components below. Key points:

• Everyone gets a single IV dose of thiamine (1 vial)
• If high risk for WE/KP or deficiency, activate aggressive replacement strategy of thiamine/folate/magnesium
• Do not use rally packs
• Valium load for most patients (Ativan for liver disease)

1.    Assess for patients at high risk of alcohol withdrawal as follows: 

CAGE > 2, h/o withdrawal seizures or previous hospitalization for alcohol use disorder.

2. If screen is positive: contact primary team for initiation of CIWA & thiamine/folate supplementation 

3. Initiate Thiamine/Folate Therapy:

□ Thiamine 200mg IV once, then 100mg PO daily x 6 days

□ Folate 1mg PO daily x 7 days

□ DO NOT utilize IV Rally Packs

□ NOTE: If high-risk for deficiency/WE (prior seizures, prior DTs, ICU admission, cognitive impairment, mental illness, or definitive/presumptive diagnosis of WE), utilize high-dose thiamine, folic acid, and magnesium replacement algorithm:

·         Thiamine 200mg q8h x 72h (PMID 20642790, 12414541, 9719389, 11304071, 21912244)

·         Folic acid 1mg IV once, then 1mg PO x 7 days (PMID 605207, 15745884)

·         Magnesium 4gm IV once over 2 hours, then 2gm IV x 3 days 

(PMID 3544909, 433814, 14080503)

4. If documented history of alcohol related seizures or delirium tremens:

□ Diazepam 10mg PO Q8h x 3 doses (Ativan for liver disease)

5. Consider Chemical Dependency Consult

6. Nursing Orders

□ Complete baseline CIWA then follow the protocol for vital sign frequency and to assess the patient’s need for symptom based treatment.

□ If patient is sleeping, do not wake the patient up to give diazepam/lorazepam or assess the patient’s   CIWA score; Assess the CIWA score when patient awakens.

□ CALL MD parameters: BP ≥ 160/100 or ≤ 80/60; HR ≥ 100 or ≤ 60; RR ≤ 10 or ≥ 20.

□ CALL MD for all CIWA ≥ 15

□ Assess patient 15 mins after each benzodiazepine dose for sedation

7. Initiate symptom triggered medical management based on CIWA Score:

·       Diazepam (Valium) preferred in most patients

·       Lorazepam (Ativan) if marked liver disease suspected or age >60

CIWA Score	Intervention
1-7 None - Mild	·  No medication indicated ·  Continue CIWA q4h ·  If CIWA <8 for 24 hours, discontinue protocol and benzodiazepine orders.
8-14 Moderate	CALL MD before dose if CIWA remains >8 on 3 consecutive assessments (12 hours).
	Standard Patient Population: ·  Diazepam 10mg PO (IV if unable to take PO) ·  Repeat CIWA and VS in 4 hours and dose according to this table	Marked liver disease or patients > 60yo: ·  Lorazepam 2mg PO (IV if unable to take PO) ·  Repeat CIWA and VS in 4 hours and dose according to this table
15-24 Severe	CALL MD for all CIWA ≥ 15
	Standard Patient Population: ·  Diazepam 15mg PO (IV if unable to take PO) ·  Repeat CIWA and VS in 2 hours and dose according to this table	Marked liver disease or patients > 60yo: ·  Lorazepam 3mg PO (IV if unable to take PO) ·  Repeat CIWA and VS in 2 hours and dose according to this table
≥25 Very severe	CALL MD for all CIWA ≥ 15. ·  Activate Rapid Response Team ·  Diazepam 20mg IV and reassess 15 min after dose for worsening agitation. ·  Repeat CIWA and VS in 30 min.
After each benzodiazepine dose: o   Assess @ 15min for signs of sedation.

                 

□ Diazepam (Valium) preferred in most patients
CIWA Score	Medication Orders – Diazepam Protocol	Nursing Orders – Diazepam Protocol
1-7 None - Mild		·  CIWA q4h ·  If CIWA <8 for 24 hours, discontinue protocol and benzodiazepine orders.
8-14 Moderate	Diazepam 10mg PO/IV q4h prn CIWA 8-14	·  Repeat CIWA and VS in 4 hours and dose according to protocol ·  CALL MD before dose if CIWA remains >8 on 3 consecutive assessments (12 hours).
15-24 Severe	Diazepam 15mg PO/IV q2h prn CIWA 15-24	·  Repeat CIWA and VS in 2 hours and dose according to protocol
≥25 Very severe	Diazepam 20mg IV q30 minutes prn CIWA ≥25	·  Activate Rapid Response Team. ·  Reassess 15 minutes after dose given for worsening agitation. ·  Repeat CIWA and VS in 30 min.

□ Lorazepam (Ativan) consider in marked liver disease or age >60
CIWA Score	Medication Orders – Lorazepam Protocol	Nursing Orders – Lorazepam Protocol
1-7 None - Mild		·  CIWA q4h ·  If CIWA <8 for 24 hours, discontinue protocol and benzodiazepine orders.
8-14 Moderate	Lorazepam 2mg PO/IV q2h prn CIWA 8-14	·  Repeat CIWA and VS in 2 hours and dose according to protocol ·  CALL MD before dose if CIWA remains >8 on 3 consecutive assessments.
15-24 Severe	Lorazepam 3 PO/IV q1h prn CIWA 15-24	·  Repeat CIWA and VS in 1 hour and dose according to protocol
≥25 Very severe	Lorazepam not recommended Diazepam 20mg IV q30 minutes prn CIWA ≥25	·   Activate Rapid Response Team. ·  Reassess 15 minutes after dose given for worsening agitation. ·  Repeat CIWA and VS in 30 min.