What is the recommended withdrawal protocol for a patient with a high level of physical dependence due to consuming 1-4 pints of vodka daily?

Alcohol Withdrawal Protocol for Heavy Drinkers (1-4 Pints Vodka Daily)

For a patient consuming 1-4 pints of vodka daily, initiate benzodiazepine-based alcohol withdrawal management with immediate thiamine supplementation, using either diazepam 10 mg orally every 3-4 hours or chlordiazepoxide 50-100 mg initially followed by 25-100 mg every 4-6 hours, with mandatory inpatient admission given the severity of dependence. 1, 2

Immediate Assessment and Stabilization

Critical First Steps

• Administer thiamine 100-500 mg IV immediately BEFORE any glucose-containing fluids to prevent Wernicke encephalopathy 1
• Assess vital signs for autonomic instability: tachycardia, hypertension, fever, sweating 1
• Evaluate for dangerous complications: dehydration, electrolyte imbalance (especially magnesium), infection, gastrointestinal bleeding, pancreatitis, hepatic encephalopathy 1
• Use CIWA-Ar scale to quantify withdrawal severity; scores ≥8 indicate need for pharmacological treatment 1

Admission Criteria

This patient requires inpatient admission based on: 1

• High level of daily consumption (1-4 pints = 375-1500 mL = extremely high physical dependence)
• Significant withdrawal symptoms expected
• Risk of withdrawal seizures and delirium tremens

Pharmacological Management Protocol

Benzodiazepine Selection and Dosing

Option 1: Diazepam (Preferred for most patients)

• Initial dose: 10 mg orally every 3-4 hours during first 24 hours 2
• Reduce to 5 mg orally 3-4 times daily as symptoms improve 2
• Diazepam provides superior seizure protection due to long half-life and active metabolites 1, 3
• The long elimination half-life creates self-tapering effect, reducing breakthrough symptoms 3

Option 2: Chlordiazepoxide

• Initial loading dose: 50-100 mg orally 1
• Follow with 25-100 mg every 4-6 hours based on CIWA-Ar scores 1
• Maximum 300 mg in first 24 hours 1
• After symptom control, taper over subsequent days 1

Critical Exception - Switch to Lorazepam if:

• Hepatic dysfunction present: use lorazepam 6-12 mg/day divided doses 1
• Elderly patient 1
• Respiratory compromise, recent head trauma, or obesity 1
• Lorazepam avoids "dose-stacking" in liver disease due to shorter half-life 1

Dosing Strategy Selection

Symptom-Triggered Approach (Preferred):

• Administer benzodiazepines when CIWA-Ar ≥8 1
• Reassess every 1-2 hours initially 4
• Titrate to mild sedation and symptom relief 5

Loading Dose Technique:

• Give diazepam 20 mg every 1-2 hours until clinical improvement or mild sedation achieved 5, 4
• Median effective treatment: 3 doses over 7.6 hours 4
• This approach prevents progression to severe complications 4

Essential Adjunctive Treatment

Thiamine Protocol

• Continue thiamine 100-300 mg/day orally throughout withdrawal 1
• Maintain for 2-3 months after withdrawal resolution 1
• Always give thiamine BEFORE glucose to prevent precipitating acute Wernicke encephalopathy 1

Fluid and Electrolyte Management

• Aggressive fluid and electrolyte replacement 1
• Pay particular attention to magnesium levels - commonly depleted in chronic alcohol use 1
• Avoid excessive water-sodium intake in patients with heart disease (risk of pulmonary edema) 6

Medications to Order PRN

• Antiemetics for nausea/vomiting 1
• Avoid anticonvulsants - they do not prevent alcohol withdrawal seizures 1, 7
• Avoid neuroleptics as monotherapy - they increase seizure risk 6

Monitoring Protocol

First 24-48 Hours

• Continuous vital sign monitoring 1
• CIWA-Ar assessments every 1-2 hours initially 1
• Monitor for progression to delirium tremens (peaks at 48-72 hours) 1
• Assess for delirium using CAM-ICU when appropriate 8

Days 3-5

• Symptoms typically peak at days 3-5 1
• Continue daily monitoring through day 5 after last drink 1
• Begin benzodiazepine taper if using long-acting agents 1

Duration of Benzodiazepine Therapy

• Do not continue benzodiazepines beyond 10-14 days due to abuse potential 1
• Most patients require treatment for maximum 7 days 6

Critical Pitfalls to Avoid

• Never administer glucose before thiamine - precipitates Wernicke encephalopathy 1
• Never use anticonvulsants for withdrawal seizures - benzodiazepines are the only proven treatment 1, 7
• Never use neuroleptics as monotherapy - increases seizure risk 6
• Never continue benzodiazepines beyond 2 weeks - creates dependence 1
• Never discharge without psychiatric consultation - mandatory for long-term planning 1

Post-Acute Management (Mandatory)

Psychiatric Consultation

• Required after stabilization for all patients 1
• Evaluation of alcohol use disorder severity 1
• Long-term abstinence planning 1

Relapse Prevention Medications (Consider After Withdrawal)

• Acamprosate 1
• Naltrexone (avoid if hepatic disease) 1
• Baclofen 1, 7
• Topiramate 1

Long-Term Follow-Up

• Complete alcohol abstinence is the primary goal 7
• Psychosocial support and counseling 7
• Regular monitoring for relapse 7

Special Considerations for Severe Cases

If benzodiazepines are ineffective or patient develops severe agitation:

• Consider ICU admission 9
• Barbiturates or propofol as second-line agents 1, 9
• Dexmedetomidine as adjunctive therapy only (does not prevent seizures) 1
• Never use dexmedetomidine as monotherapy - benzodiazepines remain mandatory 1