From the Guidelines
Patients with severe alcohol withdrawal syndrome, particularly those at high risk for delirium tremens (DT) or requiring high doses of benzodiazepines, are often more appropriate for internal medicine or ICU care rather than hospitalist management. Hospitalists should consider transfer when patients require more than 40mg of diazepam (or equivalent) every 4 hours, as indicated in the treatment guidelines for alcohol withdrawal syndrome 1. This is because high doses of benzodiazepines can lead to significant side effects, including respiratory depression, and require close monitoring.
Some key thresholds for considering transfer to internal medicine or ICU care include:
- Requiring more than 40mg of diazepam (or equivalent) every 4 hours
- Showing signs of hemodynamic instability, such as tachycardia >120 bpm or systolic blood pressure >180 mmHg
- Having a CIWA-Ar score consistently above 20 despite treatment
- Demonstrating early signs of DT, such as marked confusion, hallucinations, or seizures
- Having significant comorbidities, such as liver disease, heart failure, or respiratory compromise
- Having a history of previous DT episodes or withdrawal seizures
The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a useful tool for evaluating the severity of alcohol withdrawal syndrome, but it should be used in conjunction with clinical judgment and other factors, such as the patient's medical history and comorbidities 1. Benzodiazepines, such as chlordiazepoxide and diazepam, are the gold standard treatment for alcohol withdrawal syndrome, but other medications, such as lorazepam, may be used in certain situations, such as in patients with advanced liver disease or respiratory compromise 1.
Early recognition of high-risk features is crucial, as mortality from untreated DT can reach 15-20% [@Example@]. The physiological basis for these concerns relates to the potentially life-threatening autonomic hyperactivity and CNS excitation that occurs when chronic alcohol-induced GABA suppression and glutamate upregulation are suddenly reversed during withdrawal. Therefore, hospitalists should be vigilant in monitoring patients with alcohol withdrawal syndrome and consider transfer to internal medicine or ICU care when necessary.
From the Research
Thresholds for DT Risk and Benzodiazepine Dosing
When considering the management of alcohol withdrawal patients, the decision to admit to internal medicine instead of Hospitalist care depends on several factors, including the risk of delirium tremens (DT) and the required benzodiazepine dosing. The following thresholds and considerations may be taken into account:
- DT risk: Patients with a high risk of DT, such as those with a history of DT, severe alcohol withdrawal symptoms, or underlying medical co-morbidities (e.g., liver disease), may be more appropriate for internal medicine care 2, 3.
- Benzodiazepine dosing: Patients requiring high doses of benzodiazepines, particularly those exceeding the typical dosing range, may benefit from internal medicine care due to the increased risk of complications and the need for closer monitoring 3, 4.
- Severity of alcohol withdrawal symptoms: Patients with severe alcohol withdrawal symptoms, such as tremors, sweating, hypertension, and tachycardia, may require more intensive care and monitoring, making internal medicine a more suitable option 3, 5.
Indications for Internal Medicine Care
Internal medicine care may be indicated for patients with:
- Severe alcohol withdrawal symptoms or DT 2, 3
- Underlying medical co-morbidities, such as liver disease 2
- High benzodiazepine requirements or benzodiazepine-resistant patients 3, 5
- Need for closer monitoring and management of complications 5, 6
Considerations for Hospitalist Care
Hospitalist care may be suitable for patients with: