Template:Inpatient management of ETOH withdrawal - Revision history

Rossdonaldson1: /* Other Agents */

2022-05-31T20:26:29Z

Other Agents

← Older revision		Revision as of 20:26, 31 May 2022
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	*α-2 agonists ([[Dexmedetomidine]])		*α-2 agonists ([[Dexmedetomidine]])
	**Decrease severity of symptoms, but only supplemental to GABA-ergic first-lines		**Decrease severity of symptoms, but only supplemental to GABA-ergic first-lines
	**Dexmedetomidine drip, start 0.2 mcg/kg/hr, likely needing no more than 0.7 mcg/kg/hr		**Dexmedetomidine drip, start 0.2 mcg/kg/hr, likely needing no more than 0.7 mcg/kg/hr<ref>Rayner SG, et al. Dexmedetomidine as adjunct treatment for severe alcohol withdrawal in the ICU. Ann Intensive Care. 2012; 2: 12. Published online 2012 May 23. doi: 10.1186/2110-5820-2-12.</ref>
	*[[Ketamine]]		*[[Ketamine]]
	**May have some use in refractory cases		**May have some use in refractory cases

Navrdd: /* Other Agents */

2022-05-18T15:22:17Z

Other Agents

← Older revision		Revision as of 15:22, 18 May 2022
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	*α-2 agonists ([[Dexmedetomidine]])		*α-2 agonists ([[Dexmedetomidine]])
	**Decrease severity of symptoms, but only supplemental to GABA-ergic first-lines		**Decrease severity of symptoms, but only supplemental to GABA-ergic first-lines
	**Dexmedetomidine drip, start 0.2 mcg/kg/~~min~~, likely needing no more than 0.7 mcg/kg/~~min~~		**Dexmedetomidine drip, start 0.2 mcg/kg/hr, likely needing no more than 0.7 mcg/kg/hr
	*[[Ketamine]]		*[[Ketamine]]
	**May have some use in refractory cases		**May have some use in refractory cases

Rossdonaldson1: /* Benzodiazepine overview */

2020-10-24T09:31:43Z

Benzodiazepine overview

← Older revision		Revision as of 09:31, 24 October 2020
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	\| align="center" style="background:#f0f0f0;"\|'''Metabolism'''		\| align="center" style="background:#f0f0f0;"\|'''Metabolism'''
	\|-		\|-
	\| Chlordiazepoxide\|\|25\|\|PO, IV\|\|30 - 120\|\|7-28\|\|CYP; active metabolites		\| [[Chlordiazepoxide]]\|\|25\|\|PO, IV\|\|30 - 120\|\|7-28\|\|CYP; active metabolites
	\|-		\|-
	\| Diazepam\|\|5\|\|PO, IV, IM\|\|2 - 5\|\|20-120\|\|CYP; active metabolites		\| [[Diazepam]]\|\|5\|\|PO, IV, IM\|\|2 - 5\|\|20-120\|\|CYP; active metabolites
	\|-		\|-
	\| Lorazepam\|\|1\|\|PO, IM, IV\|\|15-20\|\|8-19\|\|Glucuronidation		\| [[Lorazepam]]\|\|1\|\|PO, IM, IV\|\|15-20\|\|8-19\|\|Glucuronidation
	\|}		\|}

Rossdonaldson1 at 09:31, 24 October 2020

2020-10-24T09:31:20Z

← Older revision		Revision as of 09:31, 24 October 2020
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	**Half-life 10-20 h (medium acting)		**Half-life 10-20 h (medium acting)

	===[[Propofol]]~~===~~		===Other Agents===
	*If patient does not respond to high doses of [[benzodiazepines]]		''For use in cases refractory to [[benzodiazepine]] treatment
	*0.3-1.25 mg/kg up to 4 mg/kg/hr (consider intubation), for up to 48 hours		*[[Propofol]]
			**If patient does not respond to high doses of [[benzodiazepines]]
	~~===α-2 agonists ([[Dexmedetomidine]])===~~		**0.3-1.25 mg/kg up to 4 mg/kg/hr (consider intubation), for up to 48 hours
	*Decrease severity of symptoms, but only supplemental to GABA-ergic first-lines		*[[Barbiturates]] ([[Phenobarbital]])
	*~~Dexmedetomidine drip, start 0.2 mcg/kg/min, likely needing no more than 0.7 mcg/kg/min~~		**Used when refractory to [[benzodiazepines]] (consider after patient has received equivalent of 200 mg diazepam)
			***[[Phenobarbital]] 130-260 mg IV q 15-20 minutes
	~~===~~[[Barbiturates]] ([[Phenobarbital]])~~===~~		***Can also be used as a first line load at 10 mg/kg prior to giving benzodiazepines to decrease benzodiazepine requirements and ICU admissions <ref> Rosenson J, et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med. 2013; 44(3):592-598.</ref>
	*Used when refractory to [[benzodiazepines]] (consider after patient has received equivalent of 200 mg diazepam)		*α-2 agonists ([[Dexmedetomidine]])
	*[[Phenobarbital]] 130-260 mg IV q 15-20 minutes		**Decrease severity of symptoms, but only supplemental to GABA-ergic first-lines
	*Can also be used as a first line load at 10 mg/kg prior to giving benzodiazepines to decrease benzodiazepine requirements and ICU admissions <ref> Rosenson J, et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med. 2013; 44(3):592-598.</ref>		**Dexmedetomidine drip, start 0.2 mcg/kg/min, likely needing no more than 0.7 mcg/kg/min
			*[[Ketamine]]
	~~===~~[[Ketamine]]~~===~~		**May have some use in refractory cases
	*May have some use in refractory cases		**Blocks the NMDA receptor which is excited an unregulated. <ref>Wong, A et al. Evaluation of adjunctive ketamine to benzodiazepines for management of alcohol withdrawal syndrome. Ann Pharmacother. 2015 Jan;49(1):14-9. PMID: 25325907</ref>
	*Blocks the NMDA receptor which is excited an unregulated. <ref>Wong, A et al. Evaluation of adjunctive ketamine to benzodiazepines for management of alcohol withdrawal syndrome. Ann Pharmacother. 2015 Jan;49(1):14-9. PMID: 25325907</ref>

	===Special Situations===		===Special Situations===
	The propylene glycol diluent in [[lorazepam]], [[phenobarbital]], and [[diazepam]], may induce a hyperosmolar anion gap [[metabolic acidosis]] if given as a drip in high doses ≥ 48hrs.<ref>Arroliga AC, Shehab N, McCarthy K, Gonzales JP. Relationship of continuous infusion [[lorazepam]] to serum propylene glycol concentration in critically ill adults. Critical Care Medicine. 2004;32(8):1709–1714. doi:10.1097/01.CCM.0000134831.40466.39.</ref> Consider alternatives such as [[propofol]] or [[dexmedetomidine]] if patients need long term sedation for [[delirium tremens]].		The propylene glycol diluent in [[lorazepam]], [[phenobarbital]], and [[diazepam]], may induce a hyperosmolar anion gap [[metabolic acidosis]] if given as a drip in high doses ≥ 48hrs.<ref>Arroliga AC, Shehab N, McCarthy K, Gonzales JP. Relationship of continuous infusion [[lorazepam]] to serum propylene glycol concentration in critically ill adults. Critical Care Medicine. 2004;32(8):1709–1714. doi:10.1097/01.CCM.0000134831.40466.39.</ref> Consider alternatives such as [[propofol]] or [[dexmedetomidine]] if patients need long term sedation for [[delirium tremens]].

Rossdonaldson1: Created page with "===Benzodiazepine overview=== {| {{table}} | align="center" style="background:#f0f0f0;"|'''Agents''' | align="center" style="background:#f0f0f0;"|'''Equivalent PO dose (mg)'''..."

2020-10-24T09:25:10Z

Created page with "===Benzodiazepine overview=== {| {{table}} | align="center" style="background:#f0f0f0;"|'''Agents''' | align="center" style="background:#f0f0f0;"|'''Equivalent PO dose (mg)'''..."

New page

===Benzodiazepine overview===
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Agents'''
| align="center" style="background:#f0f0f0;"|'''Equivalent PO dose (mg)'''
| align="center" style="background:#f0f0f0;"|'''Route'''
| align="center" style="background:#f0f0f0;"|'''Onset of Action (min)'''
| align="center" style="background:#f0f0f0;"|'''Half Life (hr)'''
| align="center" style="background:#f0f0f0;"|'''Metabolism'''
|-
| Chlordiazepoxide||25||PO, IV||30 - 120||7-28||CYP; active metabolites
|-
| Diazepam||5||PO, IV, IM||2 - 5||20-120||CYP; active metabolites
|-
| Lorazepam||1||PO, IM, IV||15-20||8-19||Glucuronidation
|}

===[[Benzodiazepines]]===
*[[Diazepam]] (Valium) 5-10 mg IV (depending on severity)
**May repeat q5-10 min for severe withdrawal (may increase dose by 10 mg every 5-10 min until desired effect achieved, max dose of 200 mg)
**Half-life 20-100 h (long acting)
*[[Lorazepam]] (Ativan) 1-4mg IV (depending on severity)
**May repeat q15-20 min for severe withdrawal (titrated to effect)
**Rarely causes hepatitis, as opposed to diazepam which may cause a cholestatic hepatitis<ref>National Institute of Diabetes and Digestive and Kidney Diseases. Lorazepam Drug Record. http://livertox.nih.gov/Lorazepam.htm</ref>
**Half-life 10-20 h (medium acting)

===[[Propofol]]===
*If patient does not respond to high doses of [[benzodiazepines]]
*0.3-1.25 mg/kg up to 4 mg/kg/hr (consider intubation), for up to 48 hours

===α-2 agonists ([[Dexmedetomidine]])===
*Decrease severity of symptoms, but only supplemental to GABA-ergic first-lines
*Dexmedetomidine drip, start 0.2 mcg/kg/min, likely needing no more than 0.7 mcg/kg/min

===[[Barbiturates]] ([[Phenobarbital]])===
*Used when refractory to [[benzodiazepines]] (consider after patient has received equivalent of 200 mg diazepam)
*[[Phenobarbital]] 130-260 mg IV q 15-20 minutes
*Can also be used as a first line load at 10 mg/kg prior to giving benzodiazepines to decrease benzodiazepine requirements and ICU admissions <ref> Rosenson J, et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med. 2013; 44(3):592-598.</ref>

===[[Ketamine]]===
*May have some use in refractory cases
*Blocks the NMDA receptor which is excited an unregulated. <ref>Wong, A et al. Evaluation of adjunctive ketamine to benzodiazepines for management of alcohol withdrawal syndrome. Ann Pharmacother. 2015 Jan;49(1):14-9. PMID: 25325907</ref>

===Special Situations===
*The propylene glycol diluent in [[lorazepam]], [[phenobarbital]], and [[diazepam]], may induce a hyperosmolar anion gap [[metabolic acidosis]] if given as a drip in high doses ≥ 48hrs.<ref>Arroliga AC, Shehab N, McCarthy K, Gonzales JP. Relationship of continuous infusion [[lorazepam]] to serum propylene glycol concentration in critically ill adults*. Critical Care Medicine. 2004;32(8):1709–1714. doi:10.1097/01.CCM.0000134831.40466.39.</ref> Consider alternatives such as [[propofol]] or [[dexmedetomidine]] if patients need long term sedation for [[delirium tremens]].