Can delirium tremens (DTs) occur 15 days after the last alcohol consumption following a prolonged intensive care unit (ICU) stay?

From the Guidelines

Delirium tremens (DTs) typically occurs within 48-72 hours after the last drink and rarely begins after 5-7 days of alcohol cessation, making it extremely unusual for DTs to first appear at day 15 after the last drink, especially following a prolonged ICU stay. By this point, the acute alcohol withdrawal syndrome should have resolved. If new delirium or agitation occurs at day 15, clinicians should investigate other causes such as hospital-acquired infections, medication effects, metabolic disturbances, or ICU delirium rather than attributing symptoms to alcohol withdrawal.

Key Considerations

• The timeline for DTs is well-established, with most cases occurring within 48-72 hours after the last drink, as noted in the guidelines for management of alcohol-related liver disease 1.
• The physiological basis for this timeline relates to GABA receptor adaptation during chronic alcohol use, which causes hyperexcitability when alcohol is removed, but these neuroadaptations typically normalize within 7-10 days, making true late-onset DTs physiologically implausible.
• Standard treatment for alcohol withdrawal includes benzodiazepines like diazepam (5-10mg IV/PO every 4-6 hours as needed), lorazepam (1-4mg IV/PO every 2-4 hours as needed), or chlordiazepoxide (25-100mg PO every 6 hours as needed), with dosing tailored to symptom severity using assessment tools like the CIWA-Ar scale, as recommended by the guidelines for management of alcohol-related liver disease 1.
• Thiamine supplementation (100mg IV/PO daily) is also essential to prevent Wernicke's encephalopathy.
• The management of delirium in ICU patients involves a multifaceted approach, including the use of antipsychotics, as discussed in the clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit 1.
• Preventing delirium is also crucial, and guidelines suggest a tailored, multicomponent intervention package delivered by a multidisciplinary team, as outlined in the synopsis of the national institute for health and clinical excellence guideline for prevention of delirium 1.

From the Research

Delirium Tremens Onset

• Delirium Tremens (DTs) is a severe spectrum of alcohol withdrawal that can potentially result in death if not managed promptly and adequately 2.
• The onset of DTs is not explicitly stated in the provided studies to occur at day 15 from the last drink after a long ICU stay.

Factors Influencing DTs Onset

• The prevalence of DTs in patients with alcohol dependence is nearly 2% 2.
• Liver disease as a co-morbidity is very common in patients with DTs and can complicate the clinical presentation, determine the treatment choice, and influence the outcome 2.
• Benzodiazepines are the mainstay of treatment for DTs, with diazepam and lorazepam being preferred depending on the treatment regime and clinical context 2.

Treatment and Management

• In benzodiazepine refractory cases, Phenobarbital, propofol, and dexmedetomidine could be used 2.
• The use of benzodiazepines in the treatment of non-alcohol withdrawal related delirium is controversial, with some studies suggesting they may be useful in controlling delirium, while others indicate they may worsen the condition 3, 4.
• In patients with refractory agitation, benzodiazepines may be administered as scheduled doses or continuous infusion for palliative sedation 5.

Specific Considerations

• DTs have a high mortality rate of about 8%, making it crucial for clinicians to predict and manage them effectively 6.
• The treatment of DTs is best achieved by the use of intravenous diazepam administered at frequent intervals while closely monitoring the patient during the procedure 6.
• Benzodiazepines have an established role in the management of delirium secondary to alcohol withdrawal, but their use outside of this setting remains investigational 5.