Should John Doe be on CIWA?

[chromuffin]

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It seems like one in every ten to fifteen new admissions at my school ends up going through some kind of alcohol withdrawal. My theoretical question is this: Should every John Doe be placed on CIWA?

The hospitals I’ve been working at rarely use CIWA protocol unless the patient blatantly states they are alcoholic/gives a history of obvious alcohol abuse. It seems like such an easily preventable complication. What are your thoughts? I’m not saying every single patient, but what about every trauma patient? An unreliable patient?

 

[operaman]

Seems like just asking patients is a much more cost effective option. Otherwise you’re just increasing the burden on your nurses with minimal benefit.

CIWA itself is also reactive rather than proactive so I’m not sure if you’d prevent anything and they would still go through withdrawal. Have you seen what they actually do for CIWA? If not, have a nurse show you. Then see if you think making nurses do that to every XYZ type of patient would be helpful.

Also consider the risk of missing an alternative diagnosis. Personally, I would not want my non-alcoholic patients on it. If they start having symptoms I’d prefer to examine them myself and decide if withdrawal is the appropriate diagnosis.

 

[chromuffin]

Seems like just asking patients is a much more cost effective option. Otherwise you’re just increasing the burden on your nurses with minimal benefit.

CIWA itself is also reactive rather than proactive so I’m not sure if you’d prevent anything and they would still go through withdrawal. Have you seen what they actually do for CIWA? If not, have a nurse show you. Then see if you think making nurses do that to every XYZ type of patient would be helpful.

Also consider the risk of missing an alternative diagnosis. Personally, I would not want my non-alcoholic patients on it. If they start having symptoms I’d prefer to examine them myself and decide if withdrawal is the appropriate diagnosis.

This is understandable. I’ve seen CIWA protocol used appropriately. My question is more for unknown patients (or “John Does”) that are brought in from the street due to trauma (i.e. MVC, GSW) or patients that are found encephalopathic. Sure, speaking to family about alcohol use is appropriate if possible. What about patients that do not have family around and the patient is obtunded?

 

[curiousneuro]

This is understandable. I’ve seen CIWA protocol used appropriately. My question is more for unknown patients (or “John Does”) that are brought in from the street due to trauma (i.e. MVC, GSW) or patients that are found encephalopathic. Sure, speaking to family about alcohol use is appropriate if possible. What about patients that do not have family around and the patient is obtunded?

I think placing every single John/Jane Doe on CIWA preemptively is a bit overkill. Remember, the CIWA protocol usually requires quite a bit of work on the part of nurses during their assessments. We usually just monitor the patient; should the patient start to get agitated (and we don't know why, but suspect ETOH abuse history) then we would consider CIWA.

 

[operaman]

This is understandable. I’ve seen CIWA protocol used appropriately. My question is more for unknown patients (or “John Does”) that are brought in from the street due to trauma (i.e. MVC, GSW) or patients that are found encephalopathic. Sure, speaking to family about alcohol use is appropriate if possible. What about patients that do not have family around and the patient is obtunded?

Well I think I would still want to make my own assessment on each patient and possibly do some additional workup prior to handing out benzos on a nursing based protocol. You also run a high risk of complications from the benzos - everything from falls to paradoxical reactions to delirium. I think you would not buy much benefit by doing a default CIWA because you may only lose a few hours of treatment that probably don’t matter.

I tend to be a minimalist these days. If I wouldn’t give a med for it at home, I probably won’t write one for an inpatient. If you look at the CIWA scale, there are many non alcoholic patients who would end up getting benzos if you put them on it. It’s a great tool and actually works very well for the right patients. It wasn’t designed for everyone.

Perhaps an interesting project would be to look at these patients you’ve seen who have the surprise withdrawals and see if there isn’t a way you could identify these people better in advance. There are some labs that can suggest chronic etoh use, some imaging findings that would go along with it too. Obviously there’s a high cost in doing those but maybe you could figure out a set of risk factors that would warrant further workup and through that maybe identify people at high risk of withdrawal.

 

[Tenk]

Useless. Nonintubated, talking patients who come in off the street who need to be on CIWA will usually be intoxicated. This makes it obvious. If they aren’t intoxicated they will be withdrawing which is also pretty obvious because they will usually say something about it because nobody enjoys alcohol withdrawal. If the patient is intubated and can’t talk they will just be put on sedatives such as propofol or benzos anyways.