From the Guidelines
Delirium tremens (DTs) can indeed occur around day 15 after the last drink, though this is atypical as DTs usually develop within 48-72 hours of alcohol cessation and rarely begin after 5-7 days. In a patient with a prolonged ICU stay following bowel repair surgery, multiple factors could be contributing to delirium symptoms that might mimic DTs. These include postoperative delirium, medication effects (particularly sedatives, analgesics, or anticholinergics), metabolic disturbances, infections, or withdrawal from other substances. Management should include a thorough evaluation for these alternative causes while still providing appropriate treatment for potential late-onset alcohol withdrawal.
- The standard approach would include benzodiazepines such as lorazepam 1-2mg IV every 4-6 hours as needed or diazepam 5-10mg IV, with dosing adjusted based on symptoms, as recommended by the EASL clinical practice guidelines for the management of alcohol-related liver disease 1.
- Supportive care with IV fluids, thiamine 100mg IV/PO daily, folate supplementation, and electrolyte correction is essential.
- Close monitoring of vital signs and neurological status is crucial, as late-onset DTs can still be life-threatening.
- The unusual timing suggests that a multifactorial etiology is likely, and consultation with specialists in addiction medicine or neurology may be beneficial for optimal management of this complex presentation.
- It is also important to consider the guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit, which suggest routinely monitoring ICU patients for delirium and pursuing early mobilization to reduce the incidence and duration of delirium 1.
From the Research
Delirium Tremens (DTs) Onset and Etiologies
- DTs can occur in patients who are in alcohol withdrawal states, with a high mortality rate of about 8% 2.
- 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 2.
- Refractory DT is defined by a high requirement of intravenous diazepam with poor control of withdrawal symptoms 2.
Timing of DTs Onset
- There is no specific information in the provided studies about the exact timing of DTs onset, including whether it can occur at day 15 from the last drink.
- However, it is known that DTs can occur after a long ICU stay, and other etiologies such as bowel repair may be possible 3, 4, 5.
Other Etiologies and Treatment
- Delirium can occur in 30% of hospitalized patients and is associated with prolonged hospital stay and increased morbidity and mortality 4, 5.
- Benzodiazepines may be useful in controlling non-alcohol related delirium, but the results of uncontrolled studies have been unclear 4, 5.
- The use of benzodiazepines in the treatment of non-alcohol withdrawal related delirium is not recommended due to the scarcity of data from randomized controlled trials 3, 4, 5.
- Benzodiazepines have an established role in the management of delirium secondary to alcohol withdrawal and in patients with terminal delirium 6.