Protracted alcohol withdrawal delirium

[nexus73]

Has anyone seen alcohol withdrawal delirium stretch out 2-3 weeks before? Patient is still confused, disoriented, hallucinating. Medicine team says the alcohol withdrawal was 'the worst we've ever seen'. Patient was in the ICU for a week on precedex iv to keep hypertension under control. Brain mri shows small restricted diffusion in the pons, possible stroke vs demyelination(though sodium levels were normal throughout hospital stay). Otherwise no ongoing medical issues discovered. Not clear if he was taking benzos while drinking due to limited history. Utox was positive for benzos but he got a dose at an outside facility before utox was collected. Concerned about possible benzo withdrawal, medical team stopped benzos at 14 days and are using zyprexa to manage agitation.

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[WisNeuro]

Yup, although metabolites were also off during the withdrawal and took a while to get back up. Lasted right about two weeks. I kept trying to convince the resident covering that it wasn't WKS, and that they would clear if managed. Transferred to another unit, metabolites back on track, and tada, clear cognitive profile.

 

[nexus73]

Yup, although metabolites were also off during the withdrawal and took a while to get back up. Lasted right about two weeks. I kept trying to convince the resident covering that it wasn't WKS, and that they would clear if managed. Transferred to another unit, metabolites back on track, and tada, clear cognitive profile.

Do you mean electrolytes?

 

[WisNeuro]

Ah, yes, a typo. In this specific case, magnesium and sodium were way out of whack.

 

[Salpingo]

Has anyone seen alcohol withdrawal delirium stretch out 2-3 weeks before? Patient is still confused, disoriented, hallucinating. Medicine team says the alcohol withdrawal was 'the worst we've ever seen'. Patient was in the ICU for a week on precedex iv to keep hypertension under control. Brain mri shows small restricted diffusion in the pons, possible stroke vs demyelination(though sodium levels were normal throughout hospital stay). Otherwise no ongoing medical issues discovered. Not clear if he was taking benzos while drinking due to limited history. Utox was positive for benzos but he got a dose at an outside facility before utox was collected. Concerned about possible benzo withdrawal, medical team stopped benzos at 14 days and are using zyprexa to manage agitation.

Yeah, I've seen similar cases; I've wondered if there could be recrudescence of central pontine myelinolysis. Has the patient had complicated detoxes in the past? Or maybe they corrected hyponatremia at the outside facility?

Any neuro deficits (ataxia, dysphagia, etc)? Also, what benzo was used in the detox? Evidence of seizures (maybe he's post ictal?)

 

[nexus73]

Initially IV Ativan. Librium was the main benzo once he could take orals. Not sure about ataxia, though has some word finding and paraphasic problems. Somewhat tremulous still as well, though autonomically stable.

 

[Salpingo]

Yeah, I've seen similar cases; I've wondered if there could be recrudescence of central pontine myelinolysis. Has the patient had complicated detoxes in the past? Or maybe they corrected hyponatremia at the outside facility?

Any neuro deficits (ataxia, dysphagia, etc)? Also, what benzo was used in the detox? Evidence of seizures (maybe he's post ictal?)

Never mind, I guess CPM can occur in alcoholics even without overcorrection of hyponatremia

https://academic.oup.com/alcalc/art...Central-Pontine-and-Extrapontine-Myelinolysis

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4866352/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5004014/

 

[Crayola227]

Has anyone seen alcohol withdrawal delirium stretch out 2-3 weeks before? Patient is still confused, disoriented, hallucinating. Medicine team says the alcohol withdrawal was 'the worst we've ever seen'. Patient was in the ICU for a week on precedex iv to keep hypertension under control. Brain mri shows small restricted diffusion in the pons, possible stroke vs demyelination(though sodium levels were normal throughout hospital stay). Otherwise no ongoing medical issues discovered. Not clear if he was taking benzos while drinking due to limited history. Utox was positive for benzos but he got a dose at an outside facility before utox was collected. Concerned about possible benzo withdrawal, medical team stopped benzos at 14 days and are using zyprexa to manage agitation.

yes I have seen this

didn't help that after the acute w/d and d/c of benzos, that Haldol and Seroquel were being used in a patient that had a documented history of akathisia with one or the other, this was either mistaken for delirium or at minimum was worsening their agitation

besides all the excellent points above, I think people think that centrally acting meds for agitated delirium will "clear" the patient, but atypical antipsychotics themselves can cause delirium, they are not "cures" to delirium

my approach to delirium is to use the above drugs to control sx of delirium while the primary cause is dealt with (in this case protracted post alcohol withdrawal), at some point if these meds don't seem to be helping "to clear" the patient, it is sometimes reasonable to hold them in the case that they are causing the very thing I am trying to treat (since they can!). I've seen delirium clear just because atypicals were stopped or reduced.

Certainly as posters above mentioned, it may not be as simple as that and the clinical picture sounds complex. Just one pearl of my thoughts on protracted delirium in the face of atypical usage.

 

[FlowRate]

I'm pretty skeptical of people who invoke withdrawal after 10 days cessation from alcohol, but with an otherwise stable course. People at this community hospital think patients can *start* withdrawing up to 10 days later...

I have seen people with really bad withdrawal who were on a taper for a very long time, yes.

I've also seen people who were treated for benzo toxicity with more benzos for a very long time...