From the Guidelines
General anesthesia can precipitate alcohol withdrawal in individuals with alcohol dependence, and therefore, prophylactic measures such as benzodiazepines should be considered in patients at risk. Patients with chronic alcohol use who undergo surgery requiring general anesthesia are at risk for developing alcohol withdrawal syndrome, which can begin within hours after the last drink and may include symptoms ranging from mild anxiety and tremors to severe complications like seizures and delirium tremens. The risk is particularly high in patients who consume alcohol daily or in large amounts, with reported rates of 20% to 50% in hospitalized patients 1. This occurs because general anesthesia disrupts the body's adapted state to chronic alcohol exposure, and the sudden removal of alcohol's depressant effect on the central nervous system can lead to autonomic hyperactivity.
To prevent complications, healthcare providers should screen patients for alcohol use before surgery and may implement prophylactic measures such as administering benzodiazepines, which have frequently been the mainstay of therapy for alcohol withdrawal symptoms 1. However, benzodiazepine-sparing protocols consisting of alpha2 agonists (i.e., dexmedetomidine, guanfacine, clonidine) and/or various anticonvulsant agents (e.g., gabapentin, carbamazepine, valproic acid) have been recently proposed as alternative management strategies for alcohol withdrawal syndrome 1. For patients with known alcohol dependence, a tapering regimen of benzodiazepines may be necessary, along with thiamine supplementation (100 mg IV or orally) to prevent Wernicke's encephalopathy. Close monitoring of vital signs and neurological status is essential during the postoperative period to detect early signs of withdrawal.
Some key considerations for managing alcohol withdrawal in the perioperative period include:
- Screening patients for alcohol use before surgery
- Implementing prophylactic measures such as benzodiazepines or alternative management strategies
- Monitoring vital signs and neurological status closely during the postoperative period
- Providing thiamine supplementation to prevent Wernicke's encephalopathy
- Considering a tapering regimen of benzodiazepines for patients with known alcohol dependence, as only 20% of patients will require pharmacological intervention 1.
From the Research
General Anesthesia and Alcohol Withdrawal
- General anesthesia may precipitate alcohol withdrawal in patients with a history of chronic alcoholism, as it can lead to a decrease in the body's alcohol levels and trigger withdrawal symptoms 2, 3.
- The risk of alcohol withdrawal syndrome (AWS) is higher in patients with a history of heavy drinking, previous episodes of AWS, and lack of control over alcohol use 4.
- Patients undergoing general anesthesia are at risk of developing AWS, especially if they have a high blood alcohol concentration at hospital admission or a history of AWS episodes 4.
Predicting and Preventing Alcohol Withdrawal
- Predicting AWS risk and severity can be done using tools such as the AUDIT and AUDIT-C questionnaires, which can identify patients at high risk of developing AWS 4.
- Prophylactic medication, such as benzodiazepines, can be used to prevent AWS in patients considered at risk of severe AWS 4.
- Thiamine supplementation is also recommended for all malnourished alcohol-dependent patients to prevent complications such as Wernicke's encephalopathy 5, 4.
Treatment of Alcohol Withdrawal Syndrome
- The treatment of AWS typically involves symptom-triggered administration of intravenous benzodiazepines, with the goal of achieving a revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) or Richmond Agitation-Sedation Scale (RASS) score 4.
- Other medications, such as clonidine, dexmedetomidine, and neuroleptics, may be used as adjuncts to benzodiazepines in the treatment of AWS 4.
- General supportive and intensive care, including high-dose thiamine supplementation, are also essential in the management of severe AWS cases 4.