What should I do for a patient on CIWA (Clinical Institute Withdrawal Assessment) protocol who has already received 16mg of Ativan (lorazepam) orally and is getting worse?

Management of Worsening Alcohol Withdrawal Despite High-Dose Lorazepam

For a patient on CIWA protocol who has already received 16mg of Ativan (lorazepam) orally and is getting worse, you should immediately transition to phenobarbital or propofol for severe, refractory alcohol withdrawal that is not responding to benzodiazepines.

Assessment of Current Situation

First, confirm this is truly worsening alcohol withdrawal and not another condition:

• Verify CIWA scores are increasing despite lorazepam administration
• Rule out other causes that can mimic or exacerbate withdrawal:
  • Hypoglycemia
  • Electrolyte abnormalities
  • Infection/sepsis
  • Traumatic brain injury
  • Wernicke's encephalopathy

Immediate Management Steps

Step 1: Escalate Level of Care

• Transfer to ICU if not already there
• Continuous vital sign monitoring
• Consider intubation if respiratory status is compromised

Step 2: Add Phenobarbital

• Administer phenobarbital 1-3 mg/kg IV bolus (typically 100-200mg) 1
• Follow with maintenance infusion of 0.5 mg/kg/hour
• Usual maintenance dose: 50-100 mg/hour 1

Step 3: If Phenobarbital Ineffective

• Consider propofol (starting with 20mg loading dose followed by 50-70 mg/hour infusion) 1
• Propofol provides rapid onset sedation and can be easily titrated

Alternative Approaches

If ICU Transfer Not Immediately Available

• Add haloperidol 0.5-1 mg IV/IM for agitation component 1
• Consider chlorpromazine 12.5-25 mg IV/IM if severe agitation persists 1
• Increase monitoring frequency while awaiting transfer

For Patients with Contraindications to Phenobarbital

• Consider midazolam continuous infusion:
  • 2 mg IV bolus followed by 1 mg/hour infusion
  • Titrate bolus doses every 5 minutes as needed 1
  • If two bolus doses required in an hour, double the infusion rate

Monitoring and Supportive Care

• Continuous cardiac monitoring for QT prolongation and respiratory depression
• Frequent neurological assessments
• Maintain hydration with IV fluids
• Monitor for propylene glycol toxicity with high-dose benzodiazepines
• Check electrolytes and correct abnormalities
• Consider thiamine 500mg IV TID if not already administered
• Monitor for signs of Wernicke's encephalopathy

Important Considerations

1. High-dose benzodiazepines can lead to paradoxical agitation and iatrogenic delirium in some patients 2

2. Recent evidence suggests phenobarbital is effective as an adjunct to lorazepam in severe alcohol withdrawal with significant improvement in CIWA scores at 24 hours 3

3. Some centers are moving toward benzodiazepine-sparing protocols using gabapentin and clonidine, which have shown promising results in reducing maximum CIWA scores 4

4. If using the Minnesota Detoxification Scale (MINDS) instead of CIWA, consider front-loading with diazepam which has been shown to reduce restraint use and length of stay 5

5. Avoid abrupt discontinuation of benzodiazepines once withdrawal is controlled; implement a tapering schedule to prevent rebound symptoms

Remember that severe, refractory alcohol withdrawal that doesn't respond to standard benzodiazepine therapy represents a medical emergency with significant mortality risk if not properly managed.