Claudia D Spies1, Hilke E Otter2, Bernd Hüske2, Pranav Sinha3, Tim Neumann2, Jordan Rettig4, Erika Lenzenhuber5, Wolfgang J Kox2, Edward M Sellers6. 1. Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Schumannstrasse 20/21, 10117, Berlin, Germany. claudia.spies@charite.de. 2. Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Schumannstrasse 20/21, 10117, Berlin, Germany. 3. Institute of Clinical Chemistry, Charité-Universitätsmedizin Berlin, Berlin, Germany. 4. School of Medicine, University of Connecticut, Conn., USA. 5. Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin , Berlin, Germany. 6. Departments of Pharmacology, Medicine, and Psychiatry, University of Toronto, Toronto, Ont., Canada.
Abstract
OBJECTIVE: To examine the effect of bolus vs. continuous infusion adjustment on severity and duration of alcohol withdrawal syndrome (AWS), the medication requirements for AWS treatment, and the effect on ICU stay in surgical intensive care unit (ICU) patients. DESIGN AND SETTING: Prospective randomized, double-blind controlled trial in a surgical ICU. PATIENTS: 44 patients who developed AWS after admission to the ICU. INTERVENTIONS: Patients were randomized to either (a). a continuous infusion course of intravenous flunitrazepam (agitation), intravenous clonidine (sympathetic hyperactivity), and intravenous haloperidol (productive psychotic symptoms) if needed (infusion-titrated group), or (b). the same medication (flunitrazepam, clonidine, or haloperidol) bolus adjusted in response to the development of the signs and symptoms of AWS (bolus-titrated group). MEASUREMENTS AND RESULTS: The administration of "as-needed" medication was determined using a validated measure of the severity of AWS (Clinical Institute of Withdrawal Assessment). Although the severity of AWS did not differ between groups initially, it significantly worsened over time in the infusion-titrated group. This required a higher amount of flunitrazepam, clonidine, and haloperidol. ICU treatment was significantly shorter in the bolus-titrated group (median difference 6 days) due to a lower incidence of pneumonia (26% vs. 43%). CONCLUSIONS: We conclude that symptom-orientated bolus-titrated therapy decreases the severity and duration of AWS and of medication requirements, with clinically relevant benefits such as fewer days of ventilation, lower incidence of pneumonia, and shorter ICU stay.
RCT Entities:
OBJECTIVE: To examine the effect of bolus vs. continuous infusion adjustment on severity and duration of alcohol withdrawal syndrome (AWS), the medication requirements for AWS treatment, and the effect on ICU stay in surgical intensive care unit (ICU) patients. DESIGN AND SETTING: Prospective randomized, double-blind controlled trial in a surgical ICU. PATIENTS: 44 patients who developed AWS after admission to the ICU. INTERVENTIONS:Patients were randomized to either (a). a continuous infusion course of intravenous flunitrazepam (agitation), intravenous clonidine (sympathetic hyperactivity), and intravenous haloperidol (productive psychotic symptoms) if needed (infusion-titrated group), or (b). the same medication (flunitrazepam, clonidine, or haloperidol) bolus adjusted in response to the development of the signs and symptoms of AWS (bolus-titrated group). MEASUREMENTS AND RESULTS: The administration of "as-needed" medication was determined using a validated measure of the severity of AWS (Clinical Institute of Withdrawal Assessment). Although the severity of AWS did not differ between groups initially, it significantly worsened over time in the infusion-titrated group. This required a higher amount of flunitrazepam, clonidine, and haloperidol. ICU treatment was significantly shorter in the bolus-titrated group (median difference 6 days) due to a lower incidence of pneumonia (26% vs. 43%). CONCLUSIONS: We conclude that symptom-orientated bolus-titrated therapy decreases the severity and duration of AWS and of medication requirements, with clinically relevant benefits such as fewer days of ventilation, lower incidence of pneumonia, and shorter ICU stay.
Authors: Edward Abraham; Peter Andrews; Massimo Antonelli; Laurent Brochard; Christian Brun-Buisson; Geoffrey Dobb; Jean-Yves Fagon; Johan Groeneveld; Jordi Mancebo; Philipp Metnitz; Stefano Nava; Michael Pinsky; Peter Radermacher; Marco Ranieri; Christian Richard; Robert Tasker; Benoit Vallet Journal: Intensive Care Med Date: 2004-06-15 Impact factor: 17.440
Authors: Joyce E Fullwood; Zhila Mostaghimi; Christopher B Granger; Jeffrey B Washam; Wanda Bride; Yanfang Zhao; Bradi B Granger Journal: Am J Crit Care Date: 2013-09 Impact factor: 2.228
Authors: Jörg Martin; Anja Heymann; Katrin Bäsell; Ralf Baron; Rolf Biniek; Hartmut Bürkle; Peter Dall; Christine Dictus; Verena Eggers; Ingolf Eichler; Lothar Engelmann; Lars Garten; Wolfgang Hartl; Ulrike Haase; Ralf Huth; Paul Kessler; Stefan Kleinschmidt; Wolfgang Koppert; Franz-Josef Kretz; Heinz Laubenthal; Guenter Marggraf; Andreas Meiser; Edmund Neugebauer; Ulrike Neuhaus; Christian Putensen; Michael Quintel; Alexander Reske; Bernard Roth; Jens Scholz; Stefan Schröder; Dierk Schreiter; Jürgen Schüttler; Gerhard Schwarzmann; Robert Stingele; Peter Tonner; Philip Tränkle; Rolf Detlef Treede; Tomislav Trupkovic; Michael Tryba; Frank Wappler; Christian Waydhas; Claudia Spies Journal: Ger Med Sci Date: 2010-02-02