MASSIVE SEDATION FOR ALCOHOL WITHDRAWAL

1. Dr. GOVARTHANAN RAJENDIRAN, MBBS,
ICU RESIDENT, DEPARTMENT OF CRITICAL CARE,
APOLLO FIRST MED HOSPITALS, 154, POONAMALLEE HIGH ROAD,
KILPAUK, CHENNAI, TAMILNADU, INDIA – 632001.

2. Dr. SARAVANAN DHARMAPURI CHANDRAHASAN, MBBS, DLO,
JUNIOR CONSULTANT, DEPARTMENT OF CRITICAL CARE,
APOLLO FIRST MED HOSPITALS

3. Dr. ASHWIN KUMAR MANI, MBBS, AB(Int Med), AB(Pulm), AB(Crit Care),
CONSULTANT – PULMONARY AND CRITICAL CARE MEDICINE,
DEPARTMENT OF CRITICAL CARE,
APOLLO FIRST MED HOSPITALS

 

Abstract:

Acute alcohol withdrawal presenting as delirium tremens usually requires high doses of sedation to keep the patient calm. We report a patient with delirium tremens who required very high doses of sedation with benzodiazepines, opiate and intravenous ultra short-acting anesthetic agent. Mechanical ventilation becomes a part of the management in such cases where high doses of sedation are used. Propofol should always be considered an option in the treatment of refractory delirium tremens not responding to high doses of benzodiazepines.

Keywords: Delirium tremens – Sedation – Mechanical Ventilation.

 

Introduction:

Acute alcohol withdrawal in a chronic alcoholic can produce minor withdrawal syndrome, seizures, hallucinosis and delirium tremens. Current diagnostic criteria for delirium tremens include disturbance of consciousness, change in cognition or perceptual disturbance developing in a short period, and the emergence of symptoms during or shortly after withdrawal from heavy alcohol intake1. Delirium tremens produces disorientation, agitation, hallucinations (especially visual), tachycardia, hypertension, hyperventilation and elevated oxygen consumption. Sedation is important in the management but massive sedation usually requires mechanical ventilation. With the advances in the treatment, the mortality has dropped to almost 0% to 1% in some centers1.

Case report:

A 37 year old man was admitted with the complaints of repeated episodes of vomiting, tremors, passing high colored urine and loss of appetite. He had no other complaints including hemetemesis, melena, abdominal swelling/pain, fever and loss of weight. He had no significant history of past medical/surgical illness or illicit sexual exposure. He is a heavy smoker (10 – 15 cigarettes per day) and a heavy alcoholic (average 1 liter of whisky/day) for the past 15 years. His last alcohol consumption was one and half days prior to admission. On admission, his conjunctiva was icteric and he was anxious, tachycardic, had tremors and abdominal examination revealed hepatomegaly. His laboratory investigations revealed deranged liver function suggestive of alcoholic hepatitis, normal coagulation profile and normal renal function and serum electrolytes. HBsAg, Anti HCV and HIV ELISA were negative. Ultrasonography of the abdomen showed diffuse fatty liver. He was started on intravenous thiamine along with dextrose infusion, vitamin K and esmoprazole.
On the first day in the ICU, he required only 2 mg of intravenous lorazepam to control his minor withdrawal symptoms. From the second day, he became delirious for which he required physical restraints and massive doses of sedation which are shown in the table 1.

Table 1 - Sedative dosages used to treat severe alcohol withdrawal symptoms

	Diazepam (mg)	Lorazepam (mg)	Propofol (mg)	Chlordiaze -poxide(mg)	Midazolam (mg)	Fentanyl (µg)
Day 1		2
Day 2	22	105	1490	40	3	150
Day 3	20	173	1580	40	4	100
Day 4	25	198	1050		5	1250
Day 5	202	74	840		10	200
Day 6	101	28	400
Day 7		4
Day 8		8
TOTAL	360	592	5360	80	22	1700

(mg – milligram, µg – microgram)

 

He was maintained on continuous infusion of propofol, lorazepam and fentanyl with intermittent boluses of diazepam despite which he remained agitated. However as increasing doses of sedatives were required, patient was intubated and placed on mechanical ventilation. His sedation level was monitored using Richmond Agitation Sedation Scale2 (RASS) and was maintained between 0 to -2. His triglyceride level was frequently monitored as he was on high dose propofol infusion. Subsequently he improved, got extubated on the twelfth day but he remained drowsy and confused for nearly a week probably due to the long half life and active metabolites of diazepam. Subsequently his sensorium and liver function improved; hence he was referred to a rehabilitation centre.

Discussion:

Refractory delirium tremens is a known entity where patient requires high doses of sedation to control their delirious behaviour. Nolop3 and Lineaweaver4 et al reported cases where high dose benzodiazepines were used for delirium tremens. Mc Cowan5 et al reported a case series of delirium tremens where patients were refractory to high dose benzodiazepines and were controlled with propofol infusion. Wolf 6 and associates reported use of 12424.4 mg diazepam, 121 mg lorazepam, 3050 mg chlordiazepoxide, and 2025 mg midazolam in 8 weeks for treating delirium tremens.

We report this case where we needed high doses of intravenous benzodiazepines, propofol and fentanyl to control his delirious behaviour. Although Wolf et al reported higher doses of sedatives; these were over a period of 8 weeks whereas this patient received the medications over 8 days.

It is important for clinicians to be aware that, in refractory cases of delirium tremens, very high dose sedation and mechanical ventilation maybe needed to treat severe withdrawal symptoms. Propofol can be used to control refractory delirium tremens when the patients are not adequately responding to high doses of benzodiazepines. The side effects of high dose sedation are hypoventilation causing atelectasis, nosocomial pneumonia, respiratory arrest, metabolic acidosis & prolonged sedative effect. High dose propofol infusion can cause hypertriglyceridemia, acute pancreatitis, increases the risk of infection and rarely “propofol infusion syndrome”.

References:

1. John P. Kress, Jesse B. Hall. (2004) Delirium and sedation. Crit Care Clin. 20, 419 – 433.

2. Lineaweaver WC, Anderson K, Hing DN. (1988 Mar) Massive doses of midazolam infusion for delirium tremens without respiratory depression. Crit Care Med. 16 (3), 294-5.
3. Mc Cowan C, Marik P. (2000 Jun) Refractory delirium tremens treated with propofol: a case series. Crit Care Med. 28(6), 1781-4.
4. Michael F. Mayo-Smith, Lee H. Beecher, Timothy L. Fischer, David A. Gorelick, Jeanette L. Guillaume, Arnold Hill et al. (2004) Management of Alcohol Withdrawal Delirium. Arch Intern Med. 164, 1405-1412.
5. Nolop KB, Natow A. Unprecedented sedative requirements during delirium tremens. (1985 Apr) Crit Care Med. 13 (4), 246-7.
6. Wolf KM, Shaughnessy AF, Middleton DB. (1993) Prolonged delirium tremens requiring massive doses of medication. J Am Board Fam Pract. 6, 502-504.

 

Copyright Priory Lodge Education 2007

First Published September 2007

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