Opioid, Benzodiazepine and Alcohol Withdrawal — Clinical Case

DCE Long Case

Patient brief

Mr Hart, 47, drinks about 35 units of alcohol a day and was admitted 2 days ago after a fall. He is now agitated, sweating and tremulous, sees insects on the walls, and is disoriented. He had a withdrawal seizure during a previous assisted withdrawal programme. ^[1]

Tasks

1. Decide the level of care and the immediate treatment.
2. Plan thiamine.
3. Outline the options if he does not settle on benzodiazepines. ^[5]

Model discussion points

Level of care. NICE advises admission for medically assisted withdrawal when someone has, or is at high risk of, withdrawal seizures or delirium tremens. ^[1]

Delirium tremens. NICE advises oral lorazepam as first-line treatment, then parenteral lorazepam or haloperidol if symptoms persist or oral medication is declined. If delirium tremens develops during withdrawal treatment, review the withdrawal regimen. ^[1]

Thiamine. Offer parenteral thiamine for suspected Wernicke's encephalopathy for a minimum of 5 days unless it is excluded, keeping a high level of suspicion, particularly if the person is intoxicated. The thiamine injection label lists Wernicke's encephalopathy among the indications for rapid restoration of thiamine. ^{[1] [6]}

Benzodiazepine-resistant withdrawal. A review of critically ill patients describes an early multimodal approach to benzodiazepine-resistant withdrawal, with adjuncts including antiepileptics, baclofen, dexmedetomidine, ketamine, phenobarbital and propofol. ^[5]

In an ICU cohort, a phenobarbital protocol was associated with shorter ICU stay than a CIWA-Ar benzodiazepine protocol (2.4 versus 4.4 days). ^[3]

In benzodiazepine-resistant withdrawal, front-loaded phenobarbital (10 mg/kg intravenously over 30 minutes) was associated with less mechanical ventilation than low-intermittent dosing (28 versus 63 percent). ^[4]