What is the Clinical Institute Withdrawal Assessment (CIWA) protocol for alcohol withdrawal?

From the Guidelines

The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol is a crucial tool for evaluating and managing alcohol withdrawal syndrome, guiding medication administration and facilitating objective communication between healthcare providers 1. The CIWA protocol consists of a 10-item scale that measures symptoms such as nausea/vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headache, and orientation. Each item is scored, with a maximum total score of 67 points. Higher scores indicate more severe withdrawal.

• Typically, scores below 8 indicate mild withdrawal,
• 8-15 moderate withdrawal, and
• above 15 severe withdrawal requiring immediate intervention 1. The protocol guides medication administration, usually with benzodiazepines like diazepam (5-10mg) or lorazepam (1-2mg) given orally or intravenously based on symptom severity.
• For scores above 15, higher doses may be needed,
• and assessments are typically performed every 1-2 hours initially, then spaced out as symptoms improve 1. The CIWA protocol allows for symptom-triggered therapy rather than fixed-schedule dosing, which reduces overall medication use and hospitalization duration.
• Thiamine (100mg daily), folate, multivitamins, and adequate hydration are also essential components of alcohol withdrawal management to prevent complications like Wernicke's encephalopathy 1. The CIWA protocol's effectiveness stems from its ability to objectively quantify withdrawal severity and standardize treatment approaches, making it a valuable tool in clinical practice 1. It is worth noting that while the CIWA protocol is helpful for evaluating the severity of AWS, high scores may be seen in psychiatric conditions that are similar to AWS, such as anxiolytic withdrawal, anxiety disorder, and physical conditions such as sepsis, hepatic encephalopathy, and severe pain, and therefore, it is not recommended for a diagnosis of AWS 1.

From the Research

Overview of CIWA Protocol

• The Clinical Institute Withdrawal Assessment (CIWA) protocol is a widely used tool for assessing and managing alcohol withdrawal syndrome (AWS) 2, 3.
• The CIWA protocol evaluates the severity of AWS and guides benzodiazepine treatment for alcohol withdrawal 4.
• The protocol assesses various symptoms, including tremors, insomnia, nausea and vomiting, hallucinations, anxiety, and agitation 2.

Components of CIWA Protocol

• The CIWA-Ar (Revised) scale is a modified version of the original CIWA scale, which assesses the severity of AWS 3, 5.
• The scale evaluates symptoms such as physical disturbances, anxiety, and confusion 5.
• The CIWA-Ar scale has been translated and validated in different languages, including German 3.

Use of CIWA Protocol in Clinical Settings

• The CIWA protocol is commonly used in outpatient and inpatient settings to manage AWS 2, 4.
• The protocol is used to guide benzodiazepine treatment, with lorazepam being a safe choice for treating AWS in the elderly and patients with liver disease 6.
• However, the use of CIWA protocol in general hospitals requires mechanisms to ensure assessment of validated alcohol withdrawal risk factors, exclusion of patients who cannot communicate, and continuity of care during transitions 4.

Limitations and Controversies

• The reliability and validity of the CIWA-Ar scale have been questioned in certain patient populations, such as acutely ill or injured patients 5.
• The scale may not be suitable for patients who cannot communicate or have significant cognitive impairment 4.
• Further research is needed to develop and validate tools for assessing and managing AWS in different clinical settings 5, 4.