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.
|
Posted 11/8/15 (A Bernard/S Priest); Revised 9/26/24 (A Bernard)