FROM ANNALS OF THE AMERICAN THORACIC SOCIETY

People hospitalized with alcohol withdrawal syndrome (AWS) and treated with continuously infused high dose sedatives may not need to be intubated, as long as they are monitored for signs of worsening gas exchange and aspiration, suggests a single-center retrospective study.

Standard practice is to treat AWS patients with sedating drugs in order to mitigate the catecholamine storm and agitation. Even at low doses, these medications can cause cardiorespiratory instability and the issue of when to secure the airways of these patients has remained a clinical question.

In their study , (Ann Am Thorac Soc. 2016 Feb 1. 13[2],162-4) Dr. Robert Stewart of Texas A&M University, College Station, and his colleagues described the outcomes of 188 patients with AWS given lorazepam as a continuous infusion up to 1.2 mg per hour with intermittent boluses of 1-2 mg when their Clinical Institute Withdrawal Assessment Score was greater than 6.

Transfer to the ICU was initiated only as clinically indicated or when higher doses of continuous hypnotics were needed. For instance, 170 of the patients also received midazolam, all but 2 by continuous intravenous infusion (median total dose, 527 mg; all administered in ICU); 19 received propofol (median total dose, 6,000 mg); and 19 received dexmedetomidine (median total dose, 1,075 mg).

All patients were monitored by continuous pulse oximetry and nasal capnography and were only intubated when gas exchange worsened or macro-aspiration was observed.

No explicit criteria mandated intubation and clinicians, most of whom were ICU residents, were required to determine ad hoc the degree of gas exchange failure or apparent aspiration that warranted intubation.

Overall, 36 (19%) of the 188 patients required intubation. These patients tended to have a higher APACHE II score (greater than 10) and to receive substantially more benzodiazepine than non-intubated patients (761 mg of lorazepam equivalent vs 229 mg; P less than 0.0001).

Intubated patients also had longer hospital lengths of stays (median, 14.7 vs. 6.0 days; P less than 0.0001) and more pneumonias (58.3% vs. 5.9%; P less than 0.0001). One patient died, and had been intubated.

“Our study adds to those cited previously suggesting that high doses of sedatives can be given without mandatory intubation, provided patients are closely monitored,” the researchers said. “Whether this practice is safer and more effective than pre-emptive intubation for such patients remains an open question.”

The researchers declared no relevant conflicts of interest.

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