Introduction: Benzodiazepines (BZD) have been the hallmark of alcohol withdrawal for decades, but new research shows that antiepileptics such as phenobarbital may be a better option in patients who have moderate to high risk of alcohol withdrawal. BZD only work on GABA receptors but alcohol causes dysfunction of multiple neurotransmitters that are not fully understood. Use of benzodiazepines alone can lead to poor control of symptoms or development of delirium tremens. The goal of this project was to create a safe and effective approach to preventing alcohol withdrawal in the burn intensive care unit before the development of symptoms.

Methods: It was recognized that a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol was being implemented in about 1 in 10 patients but symptom control was not consistent. Preventative medications such as chlordiazepoxide (Librium) were used but there was no consistency on dosing or tapering schedule among providers. This practice was consistent with current research that shows BZD dosing is difficult to assess and often resulted in presentation of symptoms and require additional BZD redosing. Upon identifying the problem, the phenobarbital research was reviewed, and a quality improvement team was coordinated to develop a safe and effective protocol. The protocol developed was based on the risk of withdrawal and airway compromise. The prescribing provider evaluates amount of daily alcohol consumption, previous withdrawal episodes, and current symptoms as well as current sedation level and the patient’s ability to protect their airway (if not intubated) to determine initial dose regimen. Protocol was reviewed and approved for use in the burn critical care unit, the critical care committee, and the pharmacy.

Results: The critical care medical team felt that implementation was successful. No complications have been noted since implementation. The protocol was easy to use and implement.

Conclusions: A consistent approach to preventing alcohol withdrawal in the burn unit can be safely and effectively implemented by utilizing Phenobarbital to manage this patient population.

References and Resources

1. Tidewell, W. P. et al., (2018). Treatment of Alcohol withdrawal syndrome: Phenobarbital vs CIWA-Ar protocol. American Journal of Critical Care, 27(6), 454-460.
2. Guirguis, E. et al., (2017). Treatment of severe alcohol withdrawal: A focus on adjunctive agents. Journal of Pharmacy technology, 33(5), 204-212.