What precautions should be taken when administering intravenous (IV) injections to patients with a history of alcohol use?

Intravenous Injection Precautions in Alcoholic Patients

For patients with alcohol use history requiring IV injections, prioritize standard sterile technique with hand hygiene and clean injection sites, while being prepared to manage potential alcohol withdrawal syndrome with benzodiazepines rather than IV ethanol. 1, 2

Standard IV Injection Technique

Hand Hygiene and Site Preparation

• Perform hand hygiene with alcohol-based hand rub or soap and water before and after each patient encounter, as this is the single most important method of preventing transmission of infectious agents 1
• Clean the injection site with a new alcohol swab before injection 1
• Use gloves when performing venipuncture and other vascular-access procedures 1

Sterile Technique for Central Venous Access

• Insertion should be carried out under strict sterile conditions 1
• Use chlorhexidine solutions with alcohol for skin preparation 1
• Avoid femoral vein insertion due to increased risk of infection and thrombosis 1

Alcohol Withdrawal Considerations

Risk Assessment

Evaluate for risk factors that predict severe alcohol withdrawal syndrome:

• Chronic heavy drinking history 3
• Previous history of generalized seizures 3
• Previous history of delirium tremens 3
• Anxiety, agitation, tremor, excessive sweating, altered consciousness, or hallucinations as signs of severe withdrawal 3

Withdrawal Prevention and Management

Benzodiazepines are the gold standard treatment for alcohol withdrawal syndrome, not IV ethanol:

• Oral benzodiazepines are the best-assessed drugs for preventing severe alcohol withdrawal syndrome, particularly seizures 3
• Benzodiazepines should be given for a maximum of 7 days with generally mild adverse effects 3
• For patients with hepatic dysfunction, use short and intermediate-acting benzodiazepines (lorazepam, oxazepam) rather than long-acting ones 2

IV Ethanol: Not Recommended

Despite historical use, IV ethanol is not recommended for routine prevention or treatment of alcohol withdrawal:

• Routine use of IV ethanol is not recommended in critically ill patients due to questionable efficacy, inconsistent pharmacokinetic profile, and relatively narrow therapeutic index 4
• Studies show inconsistent IV ethanol administration practices and potentially serious clinical concerns 5
• Relative contraindications to IV ethanol include CNS trauma, liver disease, and pancreatitis 6

Essential Thiamine Supplementation

All patients with alcohol use history require thiamine supplementation to prevent Wernicke's encephalopathy:

• Administer thiamine 100-300 mg/day for all patients with alcohol withdrawal syndrome 2
• High doses are necessary to compensate for poor absorption in alcohol-dependent patients 3
• For patients with very poor nutritional status or severe complications, IV administration is preferred despite rare anaphylactic reactions 3
• WARNING: Serious hypersensitivity/anaphylactic reactions can occur with IV thiamine, especially after repeated administration 7
• Be prepared to treat anaphylactic reactions with epinephrine, oxygen, vasopressors, steroids, and antihistamines 7

Medication-Specific Precautions

Sedation Medications

Exercise caution when administering naloxone to patients with chronic opioid or alcohol use history:

• Risk of inducing acute narcotic withdrawal in patients with history of chronic opioid or drug use 1
• Monitor for signs of opioid toxicity or withdrawal when treating people who inject drugs 1

Avoid Certain Drug Classes

• Neuroleptics increase the risk of seizures in alcohol withdrawal 3
• Betablockers increase the risk of hallucinations 3
• Clonidine increases the risk of nightmares 3

People Who Inject Drugs (PWIDs) Considerations

For patients with history of injection drug use, treatment decisions should be individualized within a multidisciplinary team:

• History of intravenous drug use and recent drug use at treatment initiation are not associated with reduced treatment response 1
• Patients with ongoing social issues or history of psychiatric disease need closer monitoring and more intensive multidisciplinary support 1
• Pre-therapeutic assessment should include evaluation of housing, education, social functioning, finances, and nutrition 1

Common Pitfalls to Avoid

• Do not use IV ethanol routinely - benzodiazepines are safer and more effective 4
• Do not forget thiamine supplementation - this prevents Wernicke's encephalopathy, a medical emergency 2, 3
• Do not use neuroleptics for alcohol withdrawal - they increase seizure risk 3
• Do not assume patients without documented risk factors need aggressive withdrawal prophylaxis - 61.8% of IV ethanol recipients in one study had no documented risk factors for delirium tremens 5
• Do not neglect addressing underlying alcohol dependence - focus on achieving complete abstinence through psychosocial support and pharmacotherapy 2