Diprivan for DTs

[docB]

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Believe it or not there are a fair amount of drinkers in Vegas. I see severe DTs about once a month. By severe I mean hypertensive, tachycardic, altered, seizing getting intubated and placed on a drip. Here's my question: I use Diprivan for almost all of my intubated pts. It's a great sedative and if the neurosurgeon or someone needs an exam they can just turn it off. I have noticed that many of my DT pts get better, in terms of their vital signs and their seizures, with the Diprivan alone, before I start the Versed drip. Anyone else found this?

 

[spyderdoc]

Sorry, we don't get drinkers here in LA, so I don't know.


And if you believe that, I got a bridge I'd like to sell you in NYC.

I haven't used propofol in DT's, so my n=0. I've just been trained to use benzos to get the GABA receptors going. Alcohol DT's/seizures, as we all know, are mostly do the lack of GABA activity. Alcohol/Benzos/Barbs activate the GABA receptors, which have inhibitory (anti-seizure) effects on the brain...DT's are thought to be from lack of GABA activity, therefore uninhibited (seizures) brain activity...I am not sure that the propofol activates the GABA receptors like benzos do...Propofol may sedate the patient, but if they are still GABA deficient, they would theoretically start seizing again when they wake up? Any articles on this?
Mark

 

[DrQuinn]

Crit Care Med. 2000 Jun;28(6):1781-4. Related Articles, Links


Comment in:
Crit Care Med. 2001 May;29(5):1096-8.

Refractory delirium tremens treated with propofol: a case series.

McCowan C, Marik P.

Department of Emergency Medicine, University of Massachusetts Medical Center, Worcester, USA.

Delirium tremens, the most serious manifestation of alcohol withdrawal, occurs in approximately 5% of hospitalized alcoholics and has a mortality rate approaching 15%. Patients with delirium tremens are usually treated in an intensive care unit in which benzodiazepines form the cornerstone of therapy. In this report, we describe four patients who proved refractory to high doses of benzodiazepines and were successfully treated with a propofol infusion.

Publication Types:
Case Reports

 

[DrQuinn]

Ann Emerg Med. 1997 Dec;30(6):825-8. Related Articles, Links


Comment in:
Ann Emerg Med. 1998 Aug;32(2):271-2.

Successful use of propofol in refractory delirium tremens.

Coomes TR, Smith SW.

Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA.

Alcohol withdrawal is a common problem encountered by emergency physicians, with delirium tremens (DT) as the extreme manifestation. DT is a true medical emergency. Although benzodiazepines are the mainstay of therapy, some patients require massive amounts to control their symptoms. We report the successful use of propofol for DT refractory to benzodiazepines in a 42-year-old alcoholic man. We briefly discuss alcohol withdrawal, as well as the pharmacokinetics and adverse affects of propofol. The use of propofol in treating DT refractory to benzodiazepines has previously not been reported.

Publication Types:
Case Reports

PMID: 9398785 [PubMed - indexed for MEDLINE]

 

[DrQuinn]

Sorry for the short drop off of turd-like literature citations, but I'm on a string of night shifts so my SDN time is cut to a minimum.

But those two articles seem pretty good. I mgiht have to try it. I had a drinker last night (6 fo'tees a day for years, and for the past year has started drinking on the job) decided that Tuesday, the 17th of August would be the best day to stop drinking cold turkey. Guy took 4 mg of Ativan q hour. DIdn't intubate him but if i did I woulda used Dippy.
Q

 

[Eidolon6]

This is not new news. Propofol works fairly well for the DT window in intubated heavy drinkers. We critical care folks use it a fair amount. One has to remember though, that the seizure threshold may actually be reduuced in the recovery phase after the drug is discontinued and in patients with known seizures or hx of prior DTs may be apt to seize when the drug is shut off. Additionally, the drug is hepatically metabolized and my suffer from delayed clearance in patients with severe chronic liver disease or acute alcoholic hepatitis. Lorazepam, which degrades by Hoffman elimination, may be a better choice in this setting.

 

[roja]

I imagine using propofol in an intubated person works okay. We have several tox trained attendings from bellvue and they all use valium. I have been asking around and flipping back and forth between valium and ativan (obviously in un-intubated patients)

The reasoning I was given for valium is that valium can be redosed much more rapidly than ativan. (withing 2-3 minutes). There is also a a philosophy of basically it being impossibly to really hurt someone with PO benzos. So, you can redose the valium very quickly (po) without concerns for respiratory depression. The theory for valium over ativan also has to do with metabolites of valium, which hang around a while and thus once a patient has been adequately dosed, they can hold out longer ultimately requireing less.

I brought all this up with the tox attendings as one of them signed out a patient going to the MICU for withdrawel... she had been given a total of about 70mg of po valium in about 2 hours... I almost choked initially and then asked for explaination...

 

[Sessamoid]

My personal protocol for true DTs is doubling doses of your benzodiazepine of choice. I've gotten as high as giving 32 mg of Ativan IV at once. Good thing he got stable, because I'm not sure the pharmacy would have been able to supply a 64 mg dose.

 

[docB]

My personal protocol for true DTs is doubling doses of your benzodiazepine of choice. I've gotten as high as giving 32 mg of Ativan IV at once. Good thing he got stable, because I'm not sure the pharmacy would have been able to supply a 64 mg dose.

We used to have a protocol that used the doubling method.

Just to clarify, I'm not really advocating using propofol for DTs. I've just noticed that it works. In my ERs once the tube is in propofol is readily available to keep them from lunging out of bed while getting the benzo drip set up takes a little while. I've just noticed that often they have stabilized on the propofol prior to the benzo getting going.

I should cross post this to the PharmD forum and see what they think.

 

[Sessamoid]

I'd be very interested to hear what the pharmacists have to say on the topic.

 

[Annette]

My IM PharmDs really like librium because it will self taper. We don't have to worry about giving a patients a script of Ativan or valium when the leave the hospital.

 

[Sessamoid]

Okay, it's a slow day this morning, so I found this:

Critical Care Medicine
Volume 28 ? Number 6 ? June 2000
"Refractory delirium tremens treated with propofol: A case series"

There are several properties that make propofol an attractive drug in cases of severe alcohol withdrawal and delirium tremens. Propofol is associated with less cross tolerance than the traditional benzodiazepines, is easily titratable, and has a rapid metabolic clearance [7] [17] . In addition, propofol, as with alcohol, affects both the glutamate and GABA-A receptors [34] . Benzodiazepines are only active on GABA receptors and thus, it is hypothesized that the hypermetabolic state of severe withdrawal, not controlled with benzodiazepines, is the result of their lack of effect on the glutamate receptors.

In short, they had 4 patients in severe DTs which could not be controlled with benzos at very high dosages. The first patient had his lorazepam drip up to 84 mg/hour before they gave up on it. The second received >3600 mg of lorazepam over 3 days before resorting to propofol. The third used up >1000 mg, and the fourth had a drip up to 30 mg/hour before propofol was used. All patients had good control of vitals and agitation with propofol. Something to think about....

 

[drpcb]

We don't use diprivan in the ED. We treat many severe withdrawal/DT's at the County. While they invariable burn up benzos at ridiculous doses 64 mg of ativan repeatedly was the highest I ever saw, I am very impressed with phenobarbital and generally have good success with it. Eventually I intubate some of them when they get too drugged, but I can't recall a DT'er refractory to benzos a lot of phenobarb (260 mg boluses prn.) soft restraints, and airway protection. Prior to getting comfortable with phenobarb, we had folks on alcohol drips which are a real pain. I suppose propofol would be a reasonable third line, but it is expensive and will be required for days at a time.
Ann Emerg Med. 1987 Aug;16(8):847-50. Related Articles, Links


Intravenous phenobarbital for alcohol withdrawal and convulsions.

Young GP, Rores C, Murphy C, Dailey RH.

In a prospective, uncontrolled study, 62 alcoholic patients received IV phenobarbital (IV-PB) to treat the alcohol withdrawal (AW) syndrome. Initially 260 mg of IV-PB were administered followed by 130 mg every 30 minutes to an end point of light sedation. A mean loading dose of 598 (+/- 192) mg of IV-PB resulted in a mean increase in the serum PB level of 13.9 (+/- 4.7) microgram/mL. Thus, the serum PB level rose 1.65 micrograms/mL for each mg/kg of IV-PB administered to these adult patients in AW. Forty-six of 48 tremulous patients (96%) showed improvement in their AW tremors. None of the 38 patients who presented with AW seizures had another convulsion during a mean observation period of three hours and 47 minutes. Transient ataxia or over-sedation occurred in three of 62 patients (5%) and was exacerbated by concurrent ethanol, diazepam, or phenytoin (six of 17), who were excluded from the study. We conclude that IV-PB is a safe and efficacious therapy for mild to moderate AWS, and IV-PB may prevent AW seizures.

PMID: 3619162 [PubMed - indexed for MEDLINE]

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[Tenesma]

hoffman elimination for lorazepam??? huh?