Clinical Sobriety

[nexus73]

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Where are people at with assessing clinical sobriety these days? I'm an inpatient psychiatrist and see this documented in ED notes periodically. I'm aware of the Hack's intoxication index, though docs at my hospital don't seem to use it. Is there a formal checklist for clinical sobriety that is widely accepted, or are docs just winging it?

I was prompted to ask this after reviewing a recent ED note which seemed to contradict itself on the topic. The note read: "the patient is clearly under the influence, but in my opinion they are clinically sober." At which point they were discharged only to come back hours later with police after found wandering onto the highway.

 

[Mount Asclepius]

We’re winging it.

Do you want to leave, can walk mostly straight, and form a decent sentence? Adios amigo.

The documentation in your example is poor. They shouldn’t contradict themselves like that.

You are also more in danger of getting in trouble by holding someone against their will and taking away their rights than letting them leave mildly intoxicated.

 

[thegenius]

Where are people at with assessing clinical sobriety these days? I'm an inpatient psychiatrist and see this documented in ED notes periodically. I'm aware of the Hack's intoxication index, though docs at my hospital don't seem to use it. Is there a formal checklist for clinical sobriety that is widely accepted, or are docs just winging it?

I was prompted to ask this after reviewing a recent ED note which seemed to contradict itself on the topic. The note read: "the patient is clearly under the influence, but in my opinion they are clinically sober." At which point they were discharged only to come back hours later with police after found wandering onto the highway.

Mostly winging it. Same way with people who are under the influence of other illegal drugs like cocaine, meth, etc. They can have recently used cocaine and be "clinically sober" based on their exam. Thankfully we don't have "blood levels" for those drugs.

But it sounds like the guy above in your second paragraph needs to be arrested for public intoxication - instead of being babysat in an ER while they sober up enough to walk around.

99% of people who are drunk do not have a medical emergency and do not require the services of the ER.

 

[Rendar5]

It means either mild intoxication (as defined by icd scoring) or not intoxicated at all depending on the physician but it’s essentially informal way to say the patient is not stumbling and slurring, and can carry on a relatively normal conversation

 

[hundreddaysoff]

Agree w/ all above that we're making this up. And, that consistency in charting this is very important, as with charting anything.

Original note writer's dilemma would have been avoided by "protective custody", in which ER calls the police and they escort pt to drunk tank overnight.

Not sure which localities can and will legally do this. But my current one does and it's very nice to use it in the middle of the night. I imagine that in reality, any local police force that will do this needs to have enough resources so that it's not an optics problem for them.

Didn't know about protective custody until I got my current job, as I don't recall anyone ever using it in any other ER I worked in 3 states.

 

[Groove]

Where are people at with assessing clinical sobriety these days? I'm an inpatient psychiatrist and see this documented in ED notes periodically. I'm aware of the Hack's intoxication index, though docs at my hospital don't seem to use it. Is there a formal checklist for clinical sobriety that is widely accepted, or are docs just winging it?

I was prompted to ask this after reviewing a recent ED note which seemed to contradict itself on the topic. The note read: "the patient is clearly under the influence, but in my opinion they are clinically sober." At which point they were discharged only to come back hours later with police after found wandering onto the highway.

We're winging it. We can't use something like the Hack's score with regularity because most of these patients are chronic alcoholics and what happens when you bring the BAL to normal levels in someone that drinks 750ccs of vodka a day? Exactly. Now you've got an ICU admission on your hand. If I slam them with benzos to avoid the withdrawal/DTs and let the BAL come down what have I really accomplished? Now there's a ton of librium or valium on board, sure...the BAL is now normal but they have no intention of staying sober so now I've got to worry about them going home and drinking another fifth of liquor with all this other stuff in their system. So, in general, we are documenting clinical observance of "medical sobriety" implying the ability to make medical decisions and it always helps documenting that they have a ride home and/or we find them one, etc..

In the old days we had these things called drunk tanks (jail) where publicly intoxicated people would hang out and sober up. These days it's called the ER.

Sorry you got consulted on this guy but occasionally we need some help when these crazy f**ks start breaking equipment, punching at us, grabbing our nurses and full on assaulting the medical staff. No doubt, the ED doc in question was simply trying to rule out any medial emergency and safely get the pt out the door before he/she went into DTs in the safest way possible but sometimes it's a balancing act. I do agree that the wording is a bit strange unless you are cutting and pasting his initial impression with a repeat evaluation later in the ED course.

 

[Groove]

I get that it must be frustrating for you as a psychiatrist and it's very easy to Monday quarterback the ED doc involved in the pt's care that now is no doubt annoying the hell out of you but I invite you to come hang out with us on a Friday or Sat night and see how easy it is to treat and dispo all these people safely.

 

[BoardingDoc]

I always find this particular case interesting when it comes to this topic: On duty

TL;DR: Guy shows up to the ED drunk asking for detox. He then says I want to leave. No SI/HI. Able to walk on his own. Leaves the ED, hit by car, paralyzed. Sues hospital saying they shouldn't have let him leave. Guy loses. NY state supreme court rules that a treating physician has "neither the obligation nor the right to hold an intoxicated patient against his will after the person had brought himself in."

Obviously this doesn't set precedent in other states, but I found it interesting and rather refreshing.

Personally, if someone comes in drunk, regardless of what I wrote about their clinical state when they came in, whenever they're able to leave they get a line documented saying that they were clinically sober, independently ambulatory with a steady gait and requesting discharge.

 

[WhatJobDoIPick]

Med student lurkers take heed:

This thread illustrates one of the cardinal issue with EM:

You are often thrust into situations that you didn't create, cannot control, and many times there are no good outs. Your judgement from on high will depend on outcome alone, despite the
pre-outcome reasonableness of your decision. All it takes is a mildly poor outcome, a patient complaint, or a nursing sneaky stab in the back for you to be called into the principal's office.

Contrast this to a non-hospital dependent field like plastics or derm, which is barely subject to any of this. Patient doesn't like it? Well now they can find a new dermatologist. Hospital doesn't like it? Well now they can find someone else for Plastics coverage.

 

[Tiger26]

I think a lot of people have different opinions but I go with whether they can walk steadily, carry on a conversation, and take PO. I document that they are no longer clinically incapacitated by their use of alcohol.

One of the original issues for the OP that has been brought up is that we rarely test an alcohol level, because that often creates unnecessary data points in our chronic alcoholic patients who can function at .300 even though they shouldn't be legally doing certain things like operating a vehicle.

 

[CoolDoc1729]

Are you asking in general or specifically about mental health evaluation? It’s tough. Our process for psych admits is that the clinical staff evaluates the patients and the county has to approve them. We fax a form over and have to include documentation of breathalyzer or blood alcohol under 0.08 or they won’t process it. So it’s basically hold to bat under 0.08 and then say hey do you still feel suicidal? And then if so, send the form. I’d say 80% they recant when sober. Then the family calls and screams at us because they sent a petition or the police told them we will have to admit the person for whatever reason. It’s a pretty terrible system. I won’t compel someone to stay if they don’t give me any indication of self harm on reassessment. Usually they can articulate to me a half a dozen things they need or want to do over the next couple weeks and I take that as evidence they are not planning to commit suicide. Frequently by 3 am 1/4 of my ED beds are tied up with these situations.

 

[comp1]

"Clinical sobriety" is not a term, as a psychiatrist, I ever want to hear... There's legal sobriety and there's intoxication from psych perspective. I wouldn't consider doing a suicide assessment (the vast majority of the requests) on a legally drunk person. 90%+ of the time the SI will resolve with alcohol metabolism, regardless of whether they are slurring their words and stumbling around or not. Alcohol is a depressant after all.

 

[Mount Asclepius]

"Clinical sobriety" is not a term, as a psychiatrist, I ever want to hear... There's legal sobriety and there's intoxication from psych perspective. I wouldn't consider doing a suicide assessment (the vast majority of the requests) on a legally drunk person. 90%+ of the time the SI will resolve with alcohol metabolism, regardless of whether they are slurring their words and stumbling around or not. Alcohol is a depressant after all.

That’s not a practical solution for modern day EM.

Clinically sober is very much a term relevant to EM unrelated to patients requiring formal psychiatric evaluation with consultation.

We deal with a huge number of intoxicated patients on a regular basis. It’s not practical or prudent to obtain alcohol levels on everyone of them and wait for legal sobriety.

Sure, if they are suicidal, then there is more formality to the process. For the larger percentage of non-suicidal, intoxicated patients, it’s clinically sober and off you go.

 

[RuralEDDoc]

"Clinical sobriety" is not a term, as a psychiatrist, I ever want to hear... There's legal sobriety and there's intoxication from psych perspective. I wouldn't consider doing a suicide assessment (the vast majority of the requests) on a legally drunk person. 90%+ of the time the SI will resolve with alcohol metabolism, regardless of whether they are slurring their words and stumbling around or not. Alcohol is a depressant after all.

You get to choose when you see patients. The ER doesn’t. Hence different approaches.

 

[BoardingDoc]

Yes, but there's that other case where the guy won $28 million after he left the ER and laid down on the train tracks and lost both his legs...

Jury awards $28.6 million to man who lost legs when hit by Amtrak train - Trains

SACRAMENTO, Calif. — A jury on Friday awarded $28.6 million to a man who lost his legs when hit by an Amtrak train while laying on railroad tracks in Marysville, Calif, in 2016, finding varying degrees of negligence by Amtrak, a hospital, and a doctor who released him before the accident, as...

www.trains.com

Again, state by state. I was honestly shocked to see that it was NY that passed the judgement that I linked. I am in no way surprised that CA is the one that felt that this guy who decided to lie down on some train tracks is somehow entitled to millions of dollars.

 

[Rendar5]

"Clinical sobriety" is not a term, as a psychiatrist, I ever want to hear... There's legal sobriety and there's intoxication from psych perspective. I wouldn't consider doing a suicide assessment (the vast majority of the requests) on a legally drunk person. 90%+ of the time the SI will resolve with alcohol metabolism, regardless of whether they are slurring their words and stumbling around or not. Alcohol is a depressant after all.

For purposes of formal psych evals I get an alcohol level because it’s standard of care. for other purposes it is actually dangerous to wait for someone to get to a level below a DWI. Almost alcoholics will go into withdrawal well before this. Why put someone into a potential disease state just to allow them to leave the ED when there’s not even a psych question

Even though it seems informal, Most people use the term clinically sober to refer to the lack of alcohol intoxication, which has an actual ICD-10/11 definition

And the definition does not involve an alcohol level in any way shape or form.

(From actual Medicolegal research)

 

[Rendar5]

Yes, but there's that other case where the guy won $28 million after he left the ER and laid down on the train tracks and lost both his legs...

Jury awards $28.6 million to man who lost legs when hit by Amtrak train - Trains

SACRAMENTO, Calif. — A jury on Friday awarded $28.6 million to a man who lost his legs when hit by an Amtrak train while laying on railroad tracks in Marysville, Calif, in 2016, finding varying degrees of negligence by Amtrak, a hospital, and a doctor who released him before the accident, as...

www.trains.com

The only thing I believe to be reasonable in this case is that the jury found the plaintiff to share the majority of blame. I’m curious if this went to appeals (like the NY case that was reversed) and if not, what the actual eventual payout would be. I’d be surprised if it went above malpractice insurance limits.

 

[nexus73]

From my non ED perspective, if I was documenting clinical sobriety, I'd include a very brief narrative about the patient being able to accurately discuss their medical condition, they can describe the recommended treatment/follow-up, and a one liner about their plan at discharge (e.g., I'm taking the bus home, roommate is picking me up--ideally not I'm driving myself home). As well as basic descriptor of ambulating, speaking clearly, etc. Along the lines of a basic decisional capacity eval combined with AMA discharge. Beyond just saying, patient is clinically sober.

 

[Brigade4Radiant]

From my non ED perspective, if I was documenting clinical sobriety, I'd include a very brief narrative about the patient being able to accurately discuss their medical condition, they can describe the recommended treatment/follow-up, and a one liner about their plan at discharge (e.g., I'm taking the bus home, roommate is picking me up--ideally not I'm driving myself home). As well as basic descriptor of ambulating, speaking clearly, etc. Along the lines of a basic decisional capacity eval combined with AMA discharge. Beyond just saying, patient is clinically sober.

They can still drink. when they are out. Also you need to ensure that they have a ride. Documenting more doesn't necessarily help you if the patient has a bad outcome or if the nursing documentation doesn't match yours

 

[RoyBasch]

You are also more in danger of getting in trouble by holding someone against their will and taking away their rights than letting them leave mildly intoxicated.

Agreed.

I fear criminal assault of treating an unwilling patient more than civil malpractice for badness happening to a patient later determined to be too intoxicated to be allowed to refuse care.

Generally I err on the side of allowing conversant and ambulatory patients to refuse care even if there is a history of intoxication.

 

[RoyBasch]

Med student lurkers take heed:

This thread illustrates one of the cardinal issue with EM:

You are often thrust into situations that you didn't create, cannot control, and many times there are no good outs. Your judgement from on high will depend on outcome alone, despite the
pre-outcome reasonableness of your decision. All it takes is a mildly poor outcome, a patient complaint, or a nursing sneaky stab in the back for you to be called into the principal's office.

Contrast this to a non-hospital dependent field like plastics or derm, which is barely subject to any of this. Patient doesn't like it? Well now they can find a new dermatologist. Hospital doesn't like it? Well now they can find someone else for Plastics coverage.

This is an amazingly insightful take for a med student. I guarantee 99% of students don't see the challenge of the ER so pragmatically.

 

[RoyBasch]

"Clinical sobriety" is not a term, as a psychiatrist, I ever want to hear... There's legal sobriety and there's intoxication from psych perspective. I wouldn't consider doing a suicide assessment (the vast majority of the requests) on a legally drunk person. 90%+ of the time the SI will resolve with alcohol metabolism, regardless of whether they are slurring their words and stumbling around or not. Alcohol is a depressant after all.

The vast majority of these patients will be deep in clinical alcohol withdraw if you wait until they are legally sober with a BAL of 0.08.

 

[WhatJobDoIPick]

The vast majority of these patients will be deep in clinical alcohol withdraw if you wait until they are legally sober with a BAL of 0.08.

I had someone withdrawing at 0.40 the other day

 

[BoardingDoc]

I had someone withdrawing at 0.40 the other day

That seems improbable. Actually withdrawing? Or "doc, I'm withdrawing. I need Ativan"? I've seen the latter a lot and let them sleep it off. I've never seen someone actually withdrawing at 400.

 

[AlmostAnMD]

That seems improbable. Actually withdrawing? Or "doc, I'm withdrawing. I need Ativan"? I've seen the latter a lot and let them sleep it off. I've never seen someone actually withdrawing at 400.

Probably meant 0.04

I tell the nurses these people leave the moment they can stand and walk. Document that and dc. Don't waste my time. No one withdraws.

 

[Mount Asclepius]

People can sometimes withdraw at impressively high alcohol levels. I sadly saw this working with the Navajo population.

 

[thegenius]

That seems improbable. Actually withdrawing? Or "doc, I'm withdrawing. I need Ativan"? I've seen the latter a lot and let them sleep it off. I've never seen someone actually withdrawing at 400.

agreed - sometimes too much alcohol makes you feel terrible (nausea, stomach pain, dizzy, dehyrated, etc) and some of these symptoms can be construed as withdraw when it's actually just the poison itself causing the symptoms

 

[pkwraith]

Probably meant 0.04

I tell the nurses these people leave the moment they can stand and walk. Document that and dc. Don't waste my time. No one withdraws.

Yeah and that what actually happens is that in psych holding, nurses will just let them sleep until morning (whether it is in 2 hours or 12 hours) and then oh boy someone is in withdraw now. What surprise.

 

[Groove]

Are you all ever doing the phenobarb load and DC? Wasn't acquainted with it in residency but seems to be gaining popularity.

Aliem

"The most commonly recommended dosing regimen starts with a 10 mg/IBW kg bolus followed by titration every 30 minutes afterwards. Patients in the ED often can be safely phenobarbital-loaded and discharged, assuming hemodynamic stability, normal alertness, and resolution of withdrawal symptoms"

I don't. Simply because benzodiazepines work so well and why re-invent the wheel? I also never have a crystal ball. Those that ultimately DO need admission...more times than not, I've got a hospitalist on the other end who has zero experience with phenobarbital and has no idea how to proceed. I think it's probably a better option for nouveau or "Wacky Weingart" style academic centers willing to implement all your FOAMED stuff where you have a phenobarbital protocol in place and the order set has been rubber stamped by all depts along with pharmacy, etc..

I know we've got some phenobarbital converts in here but for me...call me old fashioned, but I just really prefer NOT to use medications in my arsenal that have 100+ hour half lives. Especially in a patient population where I have zero confidence that they are telling me everything they have in their system.

 

[Apollyon]

Phenobarb and alcohol just prima facie scares me, à la Marilyn Monroe.

 

[pkwraith]

Most of our community hospitals have converted to phenobarb inpatient (except for some of the smaller campuses that don't carry it). I'm not really on board with phenobarb and discharge yet. What happens when they start drinking when they get home?

 

[WhatJobDoIPick]

Phenobarb is a great drug for withdrawal. Just like Droperidol and Ketamine, these "old school" drugs are now back in vogue and are great for various indications previously thought to be "OMG SCARY!" That being said, I usually reserve Phenobarb for people I'm admitting and something like Valium for those I want to DC. This is based on "feelings" though, and I'm sure you can make a case for Phenobarb and DC.

 

[Ghee Buttersnaps]

We have a phenobarbital protocol and it has made me a convert. Saves so many admissions. You keep on giving it until withdrawal symptoms are gone or you hit a certain dose and they are still withdrawing. If better they go home. If max ED dose they are admitted. I have given some pretty big doses and so have my colleagues and have yet to hear of a single bad outcome for discharged patients (of course that doesnt mean there arent any).

Never used it in residency, also not the culture in previous jobs. I think it would be hard to use when it isnt the culture and hospitalists/intensivists aren't comfortable with it, though.

 

[Rendar5]

Seems similar to Valium which has active metabolites that allow it to function similarly when given in very high doses. Alas, all of my pharmacies stopped stocking hundreds of mg’s of iv Valium

 

[Groove]

We have a phenobarbital protocol and it has made me a convert. Saves so many admissions. You keep on giving it until withdrawal symptoms are gone or you hit a certain dose and they are still withdrawing. If better they go home. If max ED dose they are admitted. I have given some pretty big doses and so have my colleagues and have yet to hear of a single bad outcome for discharged patients (of course that doesnt mean there arent any).

Never used it in residency, also not the culture in previous jobs. I think it would be hard to use when it isnt the culture and hospitalists/intensivists aren't comfortable with it, though.

Mind posting your protocol?

 

[Mount Asclepius]

I use Phenobarbital regularly and think it is superior to Lorazepam. Ativan is the equivalent of alternating slamming the gas petal and the break. You typically end up with irregular dosing with Ativan depending upon subjective nursing CIWA calculations and timing of their evaluations. I think Ativan just leads to worsening delirium. We've all done the Ativan benzo hammer and seen the spiral down before you intubate. You really want a long acting GABA agonist. If not using Phenobarbital, then I think Diazepam is also preferable to Lorazepam.

I equate it to treating hypertension emergently with boluses of Hydralazine instead of a Nicardipine infusion. You end up with a much smoother and safer effect rather than wild swings up and down.

I typically give 260 mg of Phenobarbital for mild alcohol withdrawal followed by another 130 mg in 30 minutes if still signs of withdrawal. I'll treat with 10 mg/kg right off the bat for severe withdrawal obviously requiring admission that looks like potentially headed to the ICU. A lot of times this averts ICU admission.

People have valid concerns regarding Phenobarbital use in discharged patients. I do use more regularly for admitted patients, although not infrequently I'll also use for a patient that I think might improve enough for outpatient management. That's also why I prefer starting with lower doses for mild withdrawal. I have yet to have someone that I know of go out and immediately drink significantly on top of Phenobarbital resulting in severe respiratory/neurological depression or a bad outcome.

Groove is correct that the inpatient teams are usually less familiar with Phenobarbital. I find though that they see patients doing better and don't have a problem with it. They can subsequently treat alcohol withdrawal however they feel comfortable on the floor or in the ICU. I believe that they end up using fewer doses of benzodiazepines following ED treatment with Phenobarbital although can only speak anecdotally.

This has been out for a while, but helpful for further reading and those not familiar:
Phenobarbital for Acute Alcohol Withdrawal: A Prospective Randomized Double-Blind Placebo Controlled Study

 

[BoardingDoc]

Are you all ever doing the phenobarb load and DC? Wasn't acquainted with it in residency but seems to be gaining popularity.

Aliem

"The most commonly recommended dosing regimen starts with a 10 mg/IBW kg bolus followed by titration every 30 minutes afterwards. Patients in the ED often can be safely phenobarbital-loaded and discharged, assuming hemodynamic stability, normal alertness, and resolution of withdrawal symptoms"

Yep. Impending or mild withdrawal sx? Librium. 50 to 100mg depending on weight and what they claim to drink. Moderate withdrawal sx or worse? 10mg/kg ibw phenobarb. Observe. Redose and admit or DC depending on how they look.

 

[skougess]

I hate the idea of loading an alcohol abuse patient with phenobarbital and discharging. I have no problem doing it as an inpatient. I’ll do librium with a very stern “you have a good chance of dying if you start drinking again while taking this medicine”.

 

[Janders]

Loading an alcoholic with 10mg/kg Ibw phenobarb and having them leave AMA 4hr later is totally fine. Prescribing them a 90d supply of pheno is bad.

I believe in natural selection. We put a phenobarb protocol in place at our hospital. Mostly for ED loading then tapering orally on the floors. We publicized it, but we still had a standard ativan ciwa protocol orderset you could use.

Within 6mo we had basically all physicians convert to using phenobarb for 90% of cases. Independently. Of their own free will. Because it just works. Hit them with the dose and you’ve solved the problem 80% of the time. 20% percent of the time you find your real bad withdrawals and hit them with the rescue dose and prepare the icu.

 

[WhatJobDoIPick]

I use Phenobarbital regularly and think it is superior to Lorazepam. Ativan is the equivalent of alternating slamming the gas petal and the break. You typically end up with irregular dosing with Ativan depending upon subjective nursing CIWA calculations and timing of their evaluations. I think Ativan just leads to worsening delirium. We've all done the Ativan benzo hammer and seen the spiral down before you intubate. You really want a long acting GABA agonist. If not using Phenobarbital, then I think Diazepam is also preferable to Lorazepam.

I equate it to treating hypertension emergently with boluses of Hydralazine instead of a Nicardipine infusion. You end up with a much smoother and safer effect rather than wild swings up and down.

I typically give 260 mg of Phenobarbital for mild alcohol withdrawal followed by another 130 mg in 30 minutes if still signs of withdrawal. I'll treat with 10 mg/kg right off the bat for severe withdrawal obviously requiring admission that looks like potentially headed to the ICU. A lot of times this averts ICU admission.

People have valid concerns regarding Phenobarbital use in discharged patients. I do use more regularly for admitted patients, although not infrequently I'll also use for a patient that I think might improve enough for outpatient management. That's also why I prefer starting with lower doses for mild withdrawal. I have yet to have someone that I know of go out and immediately drink significantly on top of Phenobarbital resulting in severe respiratory/neurological depression or a bad outcome.

Groove is correct that the inpatient teams are usually less familiar with Phenobarbital. I find though that they see patients doing better and don't have a problem with it. They can subsequently treat alcohol withdrawal however they feel comfortable on the floor or in the ICU. I believe that they end up using fewer doses of benzodiazepines following ED treatment with Phenobarbital although can only speak anecdotally.

This has been out for a while, but helpful for further reading and those not familiar:
Phenobarbital for Acute Alcohol Withdrawal: A Prospective Randomized Double-Blind Placebo Controlled Study

Ativan is terrible for alcohol withdrawal. I have no idea how it became the mainstay.

Same thing for the Haldol / Ativan combo for agitation.

The last thing I want for either of the above situations is for the patient to be hammered for hours with me as babysitter.

 

[thegenius]

Ativan is terrible for alcohol withdrawal. I have no idea how it became the mainstay.

Same thing for the Haldol / Ativan combo for agitation.

The last thing I want for either of the above situations is for the patient to be hammered for hours with me as babysitter.

That is extreme. It is not terrible by any stretch of the imagination.

 

[skougess]

Loading an alcoholic with 10mg/kg Ibw phenobarb and having them leave AMA 4hr later is totally fine. Prescribing them a 90d supply of pheno is bad.

I believe in natural selection. We put a phenobarb protocol in place at our hospital. Mostly for ED loading then tapering orally on the floors. We publicized it, but we still had a standard ativan ciwa protocol orderset you could use.

Within 6mo we had basically all physicians convert to using phenobarb for 90% of cases. Independently. Of their own free will. Because it just works. Hit them with the dose and you’ve solved the problem 80% of the time. 20% percent of the time you find your real bad withdrawals and hit them with the rescue dose and prepare the icu.

What’s the advantage of phenobarb over Librium for a discharged patient though? It seems like it’s only more risk.

 

[WhatJobDoIPick]

That is extreme. It is not terrible by any stretch of the imagination.

I mean if you like snowing patients and monitoring for airway patency for 8 hours then it's awesome

 

[CoolDoc1729]

I mean if you like snowing patients and monitoring for airway patency for 8 hours then it's awesome

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.

 

[thegenius]

I mean if you like snowing patients and monitoring for airway patency for 8 hours then it's awesome

Again you appear to like lobbing extreme statements. give enough phenobarbital, you'll be monitoring for airway patency as well.

 

[thegenius]

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.

The only thing I've noticed with phenobarbital, which I use regularly now, is that patients seem not to like it as much despite getting the same physiologic improvement to benzodiazepines. I can get a HR down from 130 to 100 with pheno, ativan, valium, and librium, and pts don't feel as good when it's accomplished by pheno. But I think it's just as safe.

 

[thegenius]

Anyone ever d/c someone on phenobarbital pills? If so how do you dose it? I have..and have just done 100 BID (like if they are going to a rehab center).

 

[Janders]

What’s the advantage of phenobarb over Librium for a discharged patient though? It seems like it’s only more risk.

I don’t necessarily think a dose of pheno is better than Librium for someone that is certain to be discharged in short order. I’d prolly give them a dose of oral Valium.

My situations are usually-
Patient with likely medical admit having some withdrawal (pancreatitis + withdrawal)
Patient having significant withdrawal needing treatment primarily.
Patient with significant withdrawal requesting help with detox placement
Patient with primary psych complaint who also is having withdrawl.

In these I find a single weight based dose of pheno with a written taper sets us up for success for ED obsv and floor admissions.

At the same time, if they end up leaving ama some hours later I haven’t seen any untoward effects.

I think part of the success is that unlike an ativan ciwa that does require a lot of nursing work and some subjective ability, if I just weight based pheno load and order a taper it’s going to happen. Easy button. No hoping a new grad or overwhelmed travel RN on a floor is appropriately aggressive with their ativan ciwa.

 

[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.

 

[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.