mortality associated with inpatient BZ use

[DrAwesomo]

This is more of an IM question but I feel this forum is more suitable for this question. I am used to giving Ativan for etoh withdrawal/DT in the initial stage. If the patient is not intubated, how much Ativan can a patient get before the patient is at risk of suffering respiratory arrest? (Let's assume normal kidney and liver function, normal weight ~ 70kg, etc.) So far, I have used 6mg (first dose) without any complication but I think the limit is likely much higher. Can anyone please shine light on this?

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[deleted171991]

This is more of an IM question but I feel this forum is more suitable for this question. I am used to giving Ativan for etoh withdrawal/DT in the initial stage. If the patient is not intubated, how much Ativan can a patient get before the patient is at risk of suffering respiratory arrest? (Let's assume normal kidney and liver function, normal weight ~ 70kg, etc.) So far, I have used 6mg (first dose) without any complication but I think the limit is likely much higher. Can anyone please shine light on this?

Actually the Critical Care forum would be more suitable.

With benzos it's like with propofol: some patients will obstruct at 30 mcg/kg/min, while others will not even snore at 300. You titrate slowly, then you observe. There is no magic number for airway obstruction. If the patient has significant obstructive sleep apnea, s/he can obstruct even if minimally sedated. The limit is specific to each patient, and you can only find it out by observing the patient. Titrating is like seasoning food: you can always use more, but it's much more difficult to take it back (even with flumazenil).

There is a reason these guys should be in monitored beds. High doses typically require an ICU bed, for the possible airway issues.

If you are concerned about breathing (OSA patient), use lower doses of benzos coupled with dexmedetomidine, metoprolol, clonidine or other sympatholytic adjuvants.

 

[Planktonmd]

There is no magic number and the only way to know the right dose for a specific patient is to start low and increase the dose gradually.

 

[deleted547339]

Agree with above. Some people will be snowed with just a few milligrams. One of my colleauges emptied out the ED a few weeks ago.....I think they were giving somewhere in the neighborhood of 60mg at a time and they guy was still shaking profusely...

I think at some point you have to start worrying about the diluent.

 

[osumd]

Agree that it is patient-specific, probably for several reasons- benzodiazepine / EtOH cross tolerance, as well as the autonomic dysfunction of withdrawal.

These people have death metal and lightning in their heads, the stimulus to breathe is still there

 

[Noyac]

Where are your pts when you are giving this? ICU, floor, ER?

 

[deleted547339]

Where are your pts when you are giving this? ICU, floor, ER?

ER--> ICU

 

[fakin' the funk]

This is more of an IM question but I feel this forum is more suitable for this question. I am used to giving Ativan for etoh withdrawal/DT in the initial stage. If the patient is not intubated, how much Ativan can a patient get before the patient is at risk of suffering respiratory arrest? (Let's assume normal kidney and liver function, normal weight ~ 70kg, etc.) So far, I have used 6mg (first dose) without any complication but I think the limit is likely much higher. Can anyone please shine light on this?

This might be silly to just say out loud...

But how about trying to titrate to effect?

 

[DrAwesomo]

DT --> ICU but most etoh withdrawal does not need to be in the ICU.
If I plan to use Versed or Propofol drip for titration, obviously the patient will be in ICU. My question was more geared to the floor patient who got admitted toward the end of the shift. Of course, I won't do anything that is a risk to the patient. But my question I guess is what's a reasonable total 24 hour upper limit for Ativan without worrying about respiratory compromise. Ativan 2mg IV q4h (i.e. 12mg in 24 hours) or even 2mg alternating with 4mg (i.e. 18mg) appears pretty safe from my experience.

 

[urge]

I thought the doses needed to prevent DT were very low.

 

[DrAwesomo]

I thought the doses needed to prevent DT were very low.

Not from my experience. If the Etoh level is high like 200 and pt. is "mildly" withdrawing, the next 24 hour the pt. can easily go into severe Etoh withdrawal or DT.

 

[deleted171991]

This might be silly to just say out loud...

But how about trying to titrate to effect?

That is common sense knowledge only for anesthesiologists. For other specialties, it can be such an a-ha moment (just watch their faces when you tell them), that one wonders whether they ever cook at home and titrate anything to taste.

 

[DrAwesomo]

That is common sense knowledge only for anesthesiologists. For other specialties, it can be such an a-ha moment (just watch their faces when you tell them), that one wonders whether they ever cook at home and titrate anything to taste.

It's easy to say when you are in OR sitting on your ass taking care of 1 patient and just looking at the monitor 90% of the time for a few hours
On the floor, I would like to manage 20+ patients without the need to worry about seeing them every hour. If a patient does require hourly evaluation, that's an ICU patient usually.

 

[sluggs]

Had a patient on the cusp of DTs. Gave 40 mg IV valium. 2 hours later he was still going. Gave 80 mg valium iv. Twitchy crazy. Gave 160 mg IV valium... then comes the phenobarb... never intubated

 

[Raryn]

One of the ED docs here advocated just doubling your dose of ativan every 15 minutes until you get an effect. 2->4->8->16->32->64. Never tried that on an admitted patient and I'm not likely to.

We just place the patient on CIWA scores (as determined by nursing) and increase the frequency if necessary. Starts anywhere from 0.5-4mg every 4 hrs, the highest I've ever increased the frequency is q15minutes. Once the total dose in a shift is approaching 100mg, then I'm more likely to call our ICU.

 

[deleted547339]

One of the ED docs here advocated just doubling your dose of ativan every 15 minutes until you get an effect. 2->4->8->16->32->64. Never tried that on an admitted patient and I'm not likely to.

We just place the patient on CIWA scores (as determined by nursing) and increase the frequency if necessary. Starts anywhere from 0.5-4mg every 4 hrs, the highest I've ever increased the frequency is q15minutes. Once the total dose in a shift is approaching 100mg, then I'm more likely to call our ICU.

Yea, most of my attendings advocate doubling doses (I'm an EM resident). Seems to work pretty well.

 

[Mad Jack]

It's easy to say when you are in OR sitting on your ass taking care of 1 patient and just looking at the monitor 90% of the time for a few hours
On the floor, I would like to manage 20+ patients without the need to worry about seeing them every hour. If a patient does require hourly evaluation, that's an ICU patient usually.

I'm actually surprised you'd be handling the initial phases of DTs on the floors. We'd usually send them to stepdown to start with, where their vitals were continuously monitored and they were being seen more than once every four hours.

 

[deleted171991]

It's easy to say when you are in OR sitting on your ass taking care of 1 patient and just looking at the monitor 90% of the time for a few hours
On the floor, I would like to manage 20+ patients without the need to worry about seeing them every hour.

Then you need better nurses, no offense. Since the patient is monitored, they should be able to titrate the medication to RASS or CIWA, based on a simple PRN protocol; monitoring is their job. With proper nursing care, you shouldn't have to do much beyond initiating the protocol and maybe upping the doses once or twice, if needed. If they can titrate a heparin infusion to the PTT, this should not be rocket science either.

 

[subtle1epiphany]

I've worked in a couple university owned and affiliated medical centers, there's a huge variation that I've noticed in this and other matters. The current and previous are vastly different in terms of what goes to the ICU, even considering the nebulous nature of defining the mild critical care case.

For alcohol withdrawal here where I am now, the floors (even Med-Psych units) have a cap at a couple milligrams of lorazepam every couple hours. In my book, this is not Delirium Tremens territory, this is mild to moderate withdrawal. When I had first arrived they used some 'taper' that I never understood, now I believe it is guided by either CIWA or another validated scaled response to provide symptom-guided titration. Once in the ICU, I will differentially utilize frequent diazepam pushes at the bedside doubling the dose every second dose every 10-15 minutes. I base this on the Bellevue Hospital published experience, then I may change to lorazepam vs chlordiazepoxide etc. If they fail this, they get ventilated with an analgesic plus propofol infusion vs intermittent lorazepam with dexmedetomidine (not sure where we are with studies proving dexmed alone given risk of seizures despite sympatholysis).

In residency, we would admit to a Sub-Acute Care floor and we could run a lorazepam infusion up to 20 mg/hr with boluses on top of chlordiazepoxide orally, with an initial titration by nursing (with resident involvement) to CIWA scores. Is this a clever idea? Not always, we did have a case towards the end of my training there in which an entire bag (~50 mg) infused in around 10-20 min, that patient went to the ICU. Regardless, the ICU took them if this failed and they would just ventilate the patient with propofol and an analgesic running. This was a very different patient population, New Mexico has quite a bit of alcohol use and abuse across the state, just a reality and not a judgement.

My goal is a sleepy, yet arousable patient with a heart rate < 120/min. Adjunct medications such as beta-blockers and clonidine (essentially dexmedetomidine but less clean and elegant) are awesome, but in my mind address the peripheral sympathomimetic drive of withdrawal. They can't abrogate the CNS storm that leads to seizures, to my understanding, so I would aim to replace the alcohol with a titrated agent, then add a sympatholytic.

That's my bit.
Thoughts? Corrections?