1. Kennedy, Maureen Shawn MA, RN

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"Rehab is for quitters," reads one popular T-shirt, and judging by the prevalence of alcohol dependence (as high as 30% in some health care settings), quitting is difficult for many, and it's not without substantial risks.


Because there are differing opinions on how best to treat the most serious manifestation of alcohol withdrawal, alcohol withdrawal delirium-also known as delirium tremens-a multidisciplinary working group was formed to review the research on treatment strategies and develop an evidence-based guideline.


Delirium tremens affects about 5% of those withdrawing from ethanol. Typically developing 48 to 72 hours after the cessation of alcohol consumption, it involves severe agitation, diaphoresis, tachycardia, high fever, cardiovascular collapse, and most notoriously, altered mental status (including confusion, delusions, and hallucinations).


The evidence.

Because severe agitation is associated with other serious problems, the working group recommended treating it first. A metaanalysis of nine prospective, controlled trials revealed that sedative-hypnotic agents-benzodiazepines such as diazepam (Valium and others) and lorazepam (Ativan) and barbiturates such as pentobarbital (Nembutal) and propofol (Diprivan)-lowered the risk of death and shortened the duration of delirium. They were also associated with fewer complications than neuroleptic agents, although evidence does-n't support the use of one sedative-hypnotic agent over the other.


Neuroleptic agents were associated with higher mortality rates and longer duration of delirium, and the working group doesn't recommend that they be the "sole pharmacologic agents" used to treat delirium tremens. Not highly recommended were [beta]-adrenergic antagonists (unless used concomitantly with hypnotic-sedative drugs); magnesium and ethyl alcohol were not recommended. The group did recommend the use of thiamine (vitamin B1) for the prevention or treatment of Wernicke-Korsakoff syndrome. Paraldehyde (Paral) was not recommended.


Where nurses are needed.

Because there were no randomized, controlled trials evaluating nonpharmacologic interventions, first-hand experience was used to determine best practices. According to the authors, "Close monitoring by nursing personnel is critical in providing protection for the patient and for . . . continuous, one-to-one observation and monitoring [that] may be required to ensure safe and adequate management of agitated and disoriented patients." The authors recommend careful monitoring of vital signs and, among other laboratory values, electrolyte and fluid levels. -Doug Brandt


Mayo-Smith MF, et al. Arch Intern Med 2004;164(13)1405-12.