What is the next step in managing a patient with delirium tremens (DT) who has not recovered from delirium for 15 days?

From the Guidelines

For a patient with delirium tremens persisting for 15 days, immediate escalation of care to an intensive care unit setting is necessary, with a focus on optimizing the benzodiazepine regimen and investigating alternative or additional diagnoses. The treatment should focus on optimizing the benzodiazepine regimen, typically with high-dose diazepam (10-20mg IV every 1-2 hours) or lorazepam (2-4mg IV every 1-2 hours) titrated to control agitation while monitoring respiratory status, as benzodiazepines are considered the mainstay of alcohol withdrawal treatment 1. Consider adding phenobarbital (loading dose of 10-15mg/kg IV followed by maintenance doses of 1-2mg/kg every 12 hours) if benzodiazepines alone are insufficient. Dexmedetomidine infusion (0.2-0.7 mcg/kg/hr) may be added as an adjunct therapy.

Some key points to consider in the management of delirium tremens include:

• Ensuring comprehensive supportive care including IV fluids, thiamine (500mg IV three times daily), folate (1mg daily), and electrolyte replacement, particularly magnesium, phosphate, and potassium.
• Careful monitoring for and treatment of complications such as infections, aspiration pneumonia, or seizures is essential.
• Prolonged delirium tremens beyond the typical 3-5 day course suggests either unusually severe alcohol withdrawal or alternative/additional diagnoses that should be investigated with neuroimaging, EEG, lumbar puncture, and comprehensive metabolic workup to rule out other causes of persistent delirium.
• The use of antipsychotics, such as haloperidol, may be considered in the management of delirium, but the evidence for their use is limited, and they should be used with caution due to the risk of extrapyramidal side effects and QT prolongation 1.
• Other medications, such as olanzapine, quetiapine, and aripiprazole, may also be considered for the management of delirium, but their use should be individualized and based on the specific needs of the patient 1.

From the Research

Management of Delirium Tremens (DT)

The next step in managing a patient with delirium tremens (DT) who has not recovered from delirium for 15 days involves:

• Continuing benzodiazepine treatment, as it is the mainstay of treatment for DT 2, 3, 4
• Considering the use of high-dose benzodiazepines, such as diazepam or lorazepam, for an extended period if necessary 3
• Monitoring the patient's vital signs and adjusting the treatment regimen as needed 2, 4
• Assessing for underlying medical co-morbidities, such as liver disease, which can complicate the clinical presentation and treatment choice 4
• Considering alternative treatment options, such as phenobarbital, propofol, or dexmedetomidine, in benzodiazepine refractory cases 4

Treatment Considerations

• The treatment of DT should be individualized and based on the patient's specific needs and medical history 2, 4
• The use of benzodiazepines should be carefully monitored and adjusted to avoid adverse effects, such as metabolic acidosis 3
• Supportive therapy, including reorientation strategies and supportive medical care, is also important in the management of DT 2, 5