It's estimated that 10% of the American population as a whole are dependent on alcohol, and specifically, 25% of hospitalized patients, 48% of inpatient psychiatric patients, and at least 20% of patients seen in ambulatory care settings.1 Moreover, approximately one-half of all hospital beds are filled with patients with medical conditions related to alcohol or drug dependence, and substance-exposed births occur in roughly 11.9% of recent pregnancies.2 Finally, the Substance Abuse and Mental Health Services Admin-istration Center notes that many adolescent alcohol abusers have been drinking regularly since age 9 or 10.2 Given these statistics, patients suffering from alcohol withdrawal are admitted into the OR on a regular basis as a result of injuries that have occurred under the influence, domestic violence, and medical complications of alcohol abuse, such as gastrointestinal (GI) bleeds.
Early detection
Because alcohol remains the major drug of abuse in this country, nurses must be able to identify withdrawal symptoms and medicate patients appropriately within the first 24 hours to prevent complications of seizure and alcohol withdrawal delirium, formerly known as delirium tremens (DTs). It benefits both the patient and the nursing staff to treat alcohol withdrawal early. Unanticipated alcohol withdrawal in hospitalized patients can add to the risks and costs of the hospitalization.3
The first step in treating patients who abuse alcohol is detecting the potential for withdrawal. In 1994, the U.S. Department of Health and Human Services identified the need for routine addiction screening by nurses in their clinical practice. In the same year, the American Society of Addiction Medicine stated that all surgical patients should be screened for alcohol and other drug addictions preoperatively.4 As a result, the preoperative admissions nurse should screen for alcohol use and the possibility of alcohol withdrawal during the admission assessment to prevent complications during perioperative, postanesthesia, and postoperative levels of care. A substance use assessment is performed as part of the health history and includes substances such as tobacco, alcohol, marijuana, cocaine, methampthetamine, heroin and other opiates, and "others."
Assessment
When an alcohol assessment is completed, there are often clues to alcohol use disorders. These include the smell of alcohol on the patient's breath, hand tremors, reddened eyes, evidence of dehydration, a puffy or blotchy complexion, facial spider angioma, scleral icterus, decreased peripheral sensation, muscle wasting of the arms and legs, nausea, vomiting, tingling or itching of the skin, cognitive deficits, memory impairments, and ascites. Additionally, it's important to look for a current or past medical history of gastritis, GI bleeds, esophagitis, esophageal varices, pancreatitis, hepatitis, anemia, hypertension, uncontrolled diabet-es, and repeated trauma and visits to the ED. Recov-ering alcoholics usually readily identify themselves because they are aware of their special needs during and following surgery.
During assessment, nurses must ask how much alcohol the patient consumes each day in a nonjudgmental manner. Many times, patients will state that their alcohol intake "depends on the day." At that point, it helps to rephrase the question and ask how much the patient consumes on a typical weekday and weekend. Continue to ask until you get an answer, explaining its importance toward safe medical care. The more evasive the patient is, the more important it is to get an answer. At times, it helps to elicit information from a family member.
If the patient is highly intoxicated, surgery may need to be postponed until it's safe to anesthetize.5 Following the assessment that the patient is a regular alcohol user, the anesthesia provider and surgeon must be notified so that a withdrawal medication protocol is established and anesthetic agents can be adjusted to the patient's needs.
Symptoms
The symptoms of alcohol withdrawal can appear 4 to 12 hours after the patient's last drink, and often present while the patient is still intoxicated.4 Many long-term alcohol-dependent patients don't allow their blood alcohol level (BAL) to go below a level comfortable for them; therefore, withdrawal can begin with a BAL in the intoxicated range.4 The withdrawal symptoms are the result of the excitation of the central nervous system (CNS) due to the unexpected removal of a CNS depressant, which, in this case, is alcohol. The body adapts to the constant presence of alcohol at the cellular level. Changes actually occur to the neurotransmitter receptor sites, and thus change the neurochemical functioning of the cells. As a result, alcohol-dependent patients often need more sedation during the anesthesia phase, as well as substantially more medication for effective pain control during the postoperative phase.2 The American Society of Addiction Medicine recommends that alcohol-dependent patients be premedicated with long-acting benzodiazepines to prevent alcohol withdrawal syndrome perioperatively and postoperatively.4
It's often difficult to determine if the patient's anxiety, irritability, restlessness, tachycardia, and elevated BP are related to withdrawal or to uncontrolled pain. In many cases, it's safest to medicate for withdrawal first, determine effectiveness, and follow with pain medication.1 However, postoperative pain management is often a difficult issue with addicted patients and many times necessitates significant changes from standard practice to provide the relief required. Insuf-ficient pain medication will worsen the withdrawal syndrome and make management of both states more challenging.1 (See Alcohol withdrawal syndrome symptomatology.)
Diagnosis criteria
According to the DSM-IV-TR, the diagnostic criterion for alcohol withdrawal includes two or more of the following symptoms within several hours to a few days of cessation or reduction in alcohol:6
* autonomic hyperactivity
* increased hand tremor
* insomnia
* nausea and vomiting
* transient visual, tactile, or auditory hallucinations
* psychomotor agitation
* anxiety
* grand mal seizures.
The standard for assessment and documentation of alcohol withdrawal symptoms is the Clinical Insti-tute Withdrawal Assessment of Alcohol Scale (CIWA-Ar).2,7 Assessments must occur at least every 4 hours around the clock. If the previous assessment score is greater than 20, the patient needs reassessment in 1 to 2 hours depending on the severity of symptomatology. It's important to note that patients with significant liver disease may not exhibit symptoms for longer periods of time, even up to several days.8
Scoring
Scoring patient symptoms with the CIWA-Ar scale is systematic. Nurses can become proficient quickly by following the scoring sheet closely (see Revised Clinical Institute Withdrawal Assessment for Alcohol Scale). The scale rates severity on a scale of 0 through 7, with 7 being the most severe of classifications. Scoring must be completed preoperatively and postoperatively on a regular basis. Categories include the following:
Nausea and vomiting: By asking the patient if he or she feels nauseous and gauging the patient's reaction, the CIWA-Ar assessment score can be quickly and accurately assessed.
Tremor: To assess for tremors, the CIWA-Ar recommends having the patient extend his arms, fingers spread. However, many patients will hyperextend their arms, and the extent of the tremor may be missed. It helps to have the patient bend his elbows slightly and put his hands (palms down) onto your hands (palms up). This way, you can feel the tremor. It's also helpful to hand the patient a paper cup full of water and instruct him to drink it. A minor tremor is a fine, flutter-like tremor. If it's moderate, the patient may get the cup to his mouth with one hand but with a noticeable tremor. In a severe tremor, the patient needs both hands to get the cup to his mouth. In a full body tremor, the patient is unable to stand unassisted and tremors everywhere, including his tongue. At this degree of tremor, ask the patient to stick out his tongue for assessment.
Paroxysmal sweats: To assess sweats, rub your patient's palms, neck, and forehead to detect moisture. In a moderate sweat, you will observe sweat on the patient's forehead and palms, clamminess, and damp clothing. In severe sweats, the patient's clothing and bedding is wet, as well as his or her body. In drenching sweats, the patient's clothing and bedding will be soaked. It isn't uncommon to change the patient's clothing and bedding two or three times in a shift during severe withdrawal.
Anxiety: When assessing anxiety, it's helpful for patients to assess his or her anxiety on a scale of 1 to 10, with 10 being absolute panic. Most patients can accurately rate their anxiety. However, the nurse's observation of their behavior is also necessary.
Agitation: This isn't only observed, but also consists of a subjective feeling of being unable to be still. Watch for tossing and turning in the bed, but also ask the patient if he or she can't stop moving. It's common to see continual pacing as the patient's BAL decreases from high levels toward zero. This is often the period of time that the patient would be seeking more alcohol, so an element of craving is involved. The patient needs adequate medication at this time simply to be able to tolerate staying in the hospital. Remember that not medicating this discomfort is akin to not medicating pain in a surgical patient. These changes in mental status may precede and outlast any physiologic symptoms. Some neuroadaptive changes may be permanent, producing a sense of discomfort during abstinence.
Tactile disturbances: These may begin during the period of decreasing alcohol levels, especially itching. Itching usually occurs at the back of the neck or head, and the patient can often be seen scratching. Numbness and tingling sensations usually occur 24 hours after the last drink or later, and are usually noted in fingers, toes, forearms, and calves. Crawling feelings on the skin usually don't appear in treated withdrawal.
Auditory hallucinations: In adequately treated withdrawal, these symptoms generally don't occur. However, some patients demonstrate irritation at noise, or find noises or voices harsh.
Visual hallucinations: These also don't usually occur in adequately treated withdrawal. However, some patients find bright fluorescent hospital lights very irritating. These patients may be seen squinting if lights are introduced. Irritation at noise and light demonstrate the degree of irritability in the CNS, and warrant a quiet, darkened environment for the patient's comfort.
Headaches: As intoxication decreases, headaches, or what's frequently referred to as a "hangover," are common. As severity increases, nausea often accompanies the headache. Patients with severe headaches will grab their heads or rock their heads back and forth in their hands. Patients with liver disease can't be given acetaminophen, and those with a history of GI bleeding can't be given a nonsteroidal anti-inflammatory agent or aspirin. Lorazepam is often sufficient to ease the headache.7
Orientation or sensorium: This is assessed with simple questions like, "Where are you? What day is it? What time of day is it?" Serial sevens are assessed by asking the patient to calculate seven plus seven, and then to add another seven to assess the patient's ability to process. It's important to remember how much sedation the patient has received in assessing serial sevens. Most patients who are adequately treated become mentally clear within 2 days.
To obtain the CIWA-Ar score, simply add the numbers in each area of assessment. The score is often used to determine the amount of medication to administer in a symptom-induced medication protocol.7
Treatment
Benzodiazepines are the drug treatment of choice for alcohol withdrawal syndrome. The most commonly used drugs are lorazepam (Ativan), diazepam (Valium), and oxazepam (Serax). Some prescribers still use chlordiazepoxide (Librium), but it's generally more acceptable to use lorazepam or diazepam because they're more effective in controlling symptoms, and absorption rates are better. If the patient becomes overly sedated with diazepam, a change to lorazepam may be indicated. Patients with liver disease aren't given diazepam because of its length of action. Usually an antiemetic is also added on an as-needed basis. Antidiarrhea agents are occasionally necessary as well. The nurse should notify the prescriber if the doses are inadequate to control the withdrawal symptoms-patients should be kept comfortable during detoxification.
Nutritional supplementation with B complex vitamins, especially thiamine, are given to prevent complications that may occur from nutritional deficiencies in patients who abuse alcohol.
Keys to patient care
Early assessment and proper treatment of alcohol withdrawal contributes to a positive outcome for surgical patients. A thorough history and good observation skills often prevent unanticipated alcohol withdrawal complications. Caring for alcohol-dependent patients can be challenging, but very rewarding. They deserve our best possible care and respect. OR
Alcohol withdrawal syndrome symptomatology2
Stage 1: Begins 4 to 12 hours after last drink and lasts up to 24 hours.
* elevated BP and heart rate
* tremor
* sweating
* anxiety
* nausea
* vomiting
* insomnia
* moodiness
* hyperactive reflexes
Stage 2: Begins 24 hours after last drink.
* further elevation of BP, heart rate, and respirations
* increased tremor seen at rest
* increased anxiety and alcohol craving
* anorexia
* nausea and vomiting
* soaking sweats
* seizures (usually seen 18 to 36 hours after last drink)
* disorientation
* visual, tactile hallucinations, and illusions
Stage 3: (Usually not seen if the patient is treated for alcohol withdrawal)
* alcohol withdrawal delirium (delirium tremens) (usually after 72 hours without a drink)
* very elevated BP, heart rate, and respirations
* fever
* extreme sweats
* total body tremors at rest
* visual and tactile hallucinations
* complete disorientation
* severe agitation
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