Clinical Sobriety

[VA Hopeful Dr]

My hospital has a phenobarbital 260 mg one-time PRN CIWA over 15, as well as Ativan shortages most of the last 18 months. I created a Valium CIWA order set. I have come to strongly prefer valium for this purpose as it gives a smoother clinical course, and the phenobarbital definitely reduces the amount of Valium they end up needing. I wouldn’t choose to use Ativan anymore. In retrospect I can’t see why Ativan became the go-to. 💯 agree with you.

I was taught it was the go-to because its metabolism was not affected by cirrhosis due to a different metabolism compared to most other benzos.

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[Ghee Buttersnaps]

Mind posting your protocol?

Nothing super wild. I dont have the exact phrasing in front of me but if a patient meets criteria for "severe alcohol withdrawal" and has not received benzos or other sedating drugs recently then you give up to 10 mg/kg IBW as a bolus. There is also some room to start lower and work your way up. If the patient is still withdrawing after that you can keep giving phenobarbital until you hit 20 mg/kg IBW (consider a lower cutoff if bad CKD or cirrhosis). If withdrawal symptoms improve enough for discharge at any point up to then, you can DC. If you hit 20 mg/kg IBW and there are still withdrawal symptoms you admit the patient. Hospitalists know this and there really isnt much pushback on it. The 20 mg/kg cutoff is because once they start to get that high they need drug levels monitored from my understanding. Often they will just get put on precedex if they need admission at that point.

It is suggested to be safe to discharge up until that point and I have discharged a lot of people that have gotten around 20 mg/kg IBW phenobarbital. I see a lot of alcohol withdrawal and my ED does this quite a bit and I have yet to hear of a bad outcome but again there certainly could be ones I am not hearing about. Again if helps if everyone is giving phenobarbital for withdrawal and you arent the one person doing it while everyone else is giving ativan.

 

[Mount Asclepius]

Is there any good literature on using Precedex for alcohol withdrawal that anyone is familiar with? I’ve never seen any and yet the ICUs at several places I’ve worked at have been big into using Precedex for treatment of alcohol withdrawal. Back in residency I remember mainly using as we could extubate patients while still on Precedex. They all seemed to have prolonged courses and more delirium in my opinion than those that have received Phenobarbital or even other long acting benzodiazepines in my anecdotal experience. I’ve just had much better experience with using Phenobarbital.