ALCOHOL WITHDRAWAL MANAGEMENT PROTOCOL. To expedite treatment and ensure reproducibility, the CIWA was revised to the Clinical Institute Withdrawal Assessment-Alcohol-revised (CIWA-Ar), which is a shortened version of the scale. Nurse assesses patient’s CIWA-Ar score per alcohol withdrawal orders, ... of the initial dose of a benzodiazepine and remains on telemetry until the withdrawal orders are discontinued. 5/6/2020 24 Sedation Scale ... alcohol withdrawal protocol for this patient. • Demonstrate ability to use validated clinical tools to assess patients with these withdrawal syndromes. Alcohol Withdrawal Assessment Scoring Guidelines (CIWA - Ar) Nausea/Vomiting - Rate on scale 0 - 7 Tremors - have patient extend arms & spread fingers. Before implementation, AWS was managed in an individualized, ad hoc fashion. It should be used for non-ICU patients and ICU patients who can respond to questions. Period. h�bbd```b``:"����d�"M,��`��`��T�؁پ`r*X$H2o� 6��d�����@�b>���x#�ޕ �*������ O�8 Note also whether the symptoms occurred when the tablets were reduced or stopped, or if the symptoms occurred when the tablets were the same. The objective protocol minimizes the problem of clinical variation and over‐ and undertreatment and may lower the … According to a recent ana lysis, pa tients who con-sume more alcohol (more than 10 drinks/week) are more likely to report withdrawal symp toms.3 To avoid the lethal stages of AWS, A tally of points based on responses and observation can be used to determine treatment. If a patient is on multiple benzodiazepines, the equivalent daily doses should be added, and the patient should be started on an equivalent dose of a single long acting agent. OSU IP GEN: Alcohol . Crit Care Clin. ALCOHOL WITHDRAWAL MANAGEMENT PROTOCOL. A protocol incorporating SAS scoring and symptom-triggered benzodiazepine dosing was implemented in place of a protocol that utilized the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale and fixed benzodiazepine dosing. endstream endobj startxref endstream endobj 27 0 obj <> endobj 28 0 obj <>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/Type/Page>> endobj 29 0 obj <>stream OSU IP GEN: Alcohol . instrument, such as the Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar), a measure of withdrawal severity, or some equivalent. Don’t use alprazolam (Xanax) to treat benzo withdrawal. Benzodiazepine Withdrawal Assessment Scale. Doses were doubled when scores exceeded 20. 1–20 = mild withdrawal 41–60 = severe withdrawal 21–40 =moderate withdrawal 61–80 = very severe withdrawal Source: Adapted from Busto, U.E., Sykora, K. & Sellers, E.M. (1989). 56 0 obj <>stream • PROTOCOL FOR THE TREATMENT OF BENZODIAZEPINE WITHDRAWAL • Medical research information from a benzodiazepine withdrawal clinic Professor C Heather Ashton DM, FRCP Revised August 2002 • Ashton Manual Index Page • Contents Page • Introduction • Chapter I: … A study of the revised version of the CIWA predicted that those with a score of >15 were at increased risk for severe alcohol withdrawal (RR 3.72;95% confidence interval 2.85-4.85); the higher the score, Anecdotal studies have shown that acupuncture is … You simply have to use benzos to appropriately and effectively treat benzo withdrawal. Administer dose based on score 3. This is symptom-triggered therapy (medication given per symptoms) and has been shown to result in the use of less medication and shorter treatment times. A clinical scale to assess benzodiazepine withdrawal. 2017; 51 : 101-110 Google Scholar Risk of late onset withdrawal seizures upon abrupt cessation of shorter acting agents (oxazepam). A scale modeled after the well-validated CIWA-Ar (for alcohol withdrawal) is currently being tested for widespread use. A hospital-wide CIWA-Ar–based alcohol-withdrawal protocol was implemented on February 28, 2017, for all non-pediatric patients. However, some medications are used off-label to treat benzodiazepine withdrawal or used to manage the spectrum of symptoms that can arise during withdrawal. Lorazepam better for elderly or liver impairment, most reliable benzo for IM absorption. <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 595.4 841.8] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Assess current state of withdrawal with CIWA-Ar scoring sheet, attached. Monitor CIWA q shift for 2 days If … The CIWA-Ar scale can measure 10 symptoms. <> Nursing assessment is vitally important. No Yes - moderate Yes - … This assessment for monitoring withdrawal symptoms requires approximately 5 minutes to administer. Alcohol withdrawal protocols involving symptom-triggered administration of benzodiazepine have been established to reduce the duration of treatment and the cumulative benzodiazepine dose (relative to usual care). %���� 9 in te associated o. ond - Last Name First Name PHN# MRN# Birthdate (dd-Mon-yyyy) Physician. 2 0 obj Medications (continued) For hallucinations not controlled by adequate doses of benzodiazepines. Alcohol withdrawal protocols involving symptom-triggered administration of benzodiazepine have been established to reduce the duration of treatment and the cumulative benzodiazepine dose (relative to usual care). Treatment of Alcohol Withdrawal Syndrome: Phenobarbital Vs CIWA-Ar Protocol 20 Tidwell et al., 2018 Design Retrospective Cohort Study Objective Compared a symptom-triggered benzodiazepine protocol used in conjunction with the CIWA-Ar scale to a phenobarbital protocol Alcohol Withdrawal Protocol Give Thiamine 100mg IV initially and qd (po, IM/IV), Folate 1mg qd, MVI qd. The benzodiazepine group comprised patients who received a standard CIWA-triggered benzodiazepine protocol. Br Journal of Addict. Implementation of a Symptom-Triggered Benzodiazepine Protocol for Alcohol Withdrawal the a mount of alcohol intake and the duration of a patient’s recent drinking habit. Journal of Clinical Psychopharmacology, 9 (6), 412–416. Scores are not directly linked to pharmacological management as occurs with alcohol scores based on the CIWA-Ar. Scores of less than 8 to 10 indicate minimal to mild withdrawal. Alcohol Withdrawal Protocol. To minimize withdrawal symptoms between doses, it is recommended to convert patients to a benzodiazepine with a longer half-life, such as clonazepam, diazepam, or lorazepam. �?���X9(ZT��AոW uK�J���[�6'�g����f{����5n`����Yl�54 benzodiazepine and opioid withdrawal in acutely ill medical patients. However, BZDPs have their drawbacks: cognitive impairment, significant neurologic and medical side effects. The CIWA-B is a 22-item instrument that monitors type and severity of benzodiazepine withdrawal symptoms such as irritability, fatigue, appetite, and sleeplessness. <>>> Benzodiazepine Withdrawal Symptom Questionnaire Each moderate score is given a rating of 1 and each severe score a rating of 2. Notify MD if two consecutive CIWA scores greater than 10. To the best of our knowledge, this is the first case report of … <> The study included medical ICU patients admitted from January 1, 2016, through June 30, 2017, and treated for the onset or prevention of AWS. Vital signs to be taken daily—otherwise at the discretion of clinical staff. ?>�����c�ж�>ce1h��'me. Diazepam 5 to 10 mg IV, repeated every 5 to 10 minutes until appropriate sedation is … Journal of Clinical Psychopharmacology, 9 (6), 412–416. elect orders relacin a . Background: The Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-Ar) is an assessment tool used to quantify alcohol withdrawal syndrome (AWS) severity and inform benzodiazepine treatment for alcohol withdrawal.Objectives: To evaluate the prescribing patterns and appropriate use of the CIWA-Ar protocol in a general hospital setting, as determined by the presence … x��������"Z��w� �c;�R�v�д'�"�"��l���%9��^�ֱ]�@D>�+��!9��:��lwzv��9�����ˇ�/��޹��j�n�~�{G5���^��o�~�{�kN�ϟ���i�l��}s��#��s�յ�&����zݺ~�8߷!��l;�gU�֌ӡ5k�S�u+���І��ޭ:��U�q� Hd����6״�ukƙ� s�J����^��w �@zw��j � c��08\�����UM��m�kh������w�p���w���'X�ծy� ���9�8����%n�@:E[���[?p����ĸ�0K��qقZ���O��_�P*81J;�]V�=�>I����� �,��[e��& Med Clin North Am. Types of treatment centers available to help with benzodiazepine withdrawal include the options below. Clinical Institute Withdrawal Assessment for Benzodiazepines Scale (CIWA-B), and the Clinical Opioid Withdrawal Scale (COWS). Here we present a case of GHB withdrawal delirium that was treated successfully with fixed and symptom-triggered benzodiazepine dosing regimen based on Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) scale. The CIWA-Ar is not copyrighted and may be reproduced freely. The CIWA-Ar scale is the most sensitive tool for assessment of the patient experiencing alcohol withdrawal. Name: UR: Date Time Blood pressure Temperature Pulse Respiration rate Benzodiazepine assessment score—Range 0, 1, 4 or 7 (see next page) Give Thiamine 100mg IV initially and qd (po, IM/IV), Folate 1mg qd, MVI qd. 1. To our knowledge, this is the largest study of its kind, including 443 … ABSTRACT. If CIWA-Ar ≥ 8, treat with benzos. For patients in the ICU who are in severe withdrawal and cannot respond to questions, the MINDS protocol should be used. Early intervention for CIWA-Ar score of 8 or greater provides the best means to prevent the progression of withdrawal. Assess current state of withdrawal with CIWA-Ar scoring sheet, attached. Drug & Alcohol Services Council, SA, 2002. 1 0 obj • Discuss appropriate pharmacotherapy options for treatment of alcohol, benzodiazepine and opioid withdrawal. endstream endobj 30 0 obj <>stream x�| `TE�nU����k�� ݡIH l�H�� �Dm�� ���� ʢN2�;P�3:.3����x���PgCE�H�}u:�ν�۝:U�T�s�������:+���!V�DR�`Iu1?�]��.X�2�:�. ED length of stay, amount of benzodiazepines administered in the ED , discharge prescriptions, and unit doses (take‐away bottle of four tablets) of benzodiazepine given were recorded. Symptom‐triggered benzodiazepine dispensing based on a scale of withdrawal severity could substantially improve medical management of alcohol withdrawal. 3. The research conducted by Repper- Delisi et al. The primary investigator (See) and a medical resident collected the study data.The study methods and P. Implementation of a Symptom-Triggered Benzodiazepine Protocol for Alcohol Withdrawal . A symptom-triggered benzodiazepine protocol utilizing SAS in critically ill patients is associated with a reduction in the duration of alcohol withdrawal treatment, benzodiazepine exposure, need for mechanical ventilation, and ICU and hospital LOS compared with a CIWA based protocol using fixed benzodiazepine dosing. A symptom-triggered benzodiazepine protocol utilizing SAS and CIWA-Ar scoring for the treatment of alcohol withdrawal syndrome in the critically ill. Ann Pharm. It has been used effectively as a guidance on benzodiazepine dosing of alcohol withdrawal treatment for decades, 20 we suggested using CIWA-Ar as a tool to evaluate the severity of GHB withdrawal. Because it takes only a minute or two to administer, the scale can be used as frequently (i.e., every 1-2 hours) and can be used early when alcohol withdrawal is viewed only as a clinical risk. Prior benzodiazepine use Male sex AST: aspartate aminotransferase, AWS: alcohol withdraw al syndrome, CIWA-Ar: Clinical Institute Withdrawal Assessment for Alcohol revised Carlson RW, et al. The CIWA-Ar is a validated scoring tool for alcohol withdrawal. 2. For withdrawal symptoms: Benzodiazepine (see protocol on reverse side) Chlordiazepoxide and diazepam have longer half-lives, smoother self-taper. endobj CIWA protocol: It is a tool used commonly in the US that helps clinicians assess and treat potential alcohol withdrawal. Instead of thirty different signs, the revised version only has ten symptoms, and can be used to determine the development of alcohol withdrawal syndrome. 1997 Diagnosis of … endobj Give Thiamine mg IV initially and qd (po, IM/IV), Folate 1mg qd, MVI qd. Pearls / Other medications for acute withdrawal. Benzodiazepine Withdrawal Symptom Questionnaire Each moderate score is given a rating of 1 and each severe score a rating of 2. There are data suggesting that the alcohol recidivism rate and abu … Results: We enrolled 167 patients (135 in the preintervention and 32 in the postintervention group). However, the effects of a protocol combining fixed-schedule and symptom-triggered benzodiazepine dosing are less clear. instrument, such as the Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar), a measure of withdrawal severity, or some equivalent. In the high-dose abuse group, plasma benzodiazepine concentrations were measured daily and the 3 consecutive days of greatest relative daily fall were considered the critical withdrawal period. • … Nurse assesses patient’s CIWA-Ar score per alcohol withdrawal orders, which ranges from every 15 minutes to every 4 hours. 45 0 obj <>/Filter/FlateDecode/ID[<88EF1F194A3105B6FFFE749B2FE47325><529ED7994FB2D8408DEB3F0AEF2D09BD>]/Index[26 31]/Info 25 0 R/Length 99/Prev 326586/Root 27 0 R/Size 57/Type/XRef/W[1 3 1]>>stream By far, the most prescribed and abused benzodiazepine is Xanax (alprazolam). We propose the CIWA-B as an instrument to assess and monitor benzodiazepine-like withdrawal. Drug and Alcohol Withdrawal Clinical Practice Guidelines - NSW SummaryTo provide the most up-to-date knowledge and current level of best practice for the treatment of withdrawal from alcohol and other drugs such as heroin, and other opioids, benzodiazepines, cannabis and psychostimulants. Unfortunately, an extensively evaluated monitoring scale does not yet exist for benzodiazepine withdrawal. (2008) and Daeppen JB, Gache P, Landry U et al (2002)). %%EOF 26 0 obj <> endobj 3 0 obj To minimize withdrawal symptoms between doses, it is recommended to convert patients to a benzodiazepine with a longer half-life, such as clonazepam, diazepam, or lorazepam. Note: Total Score is indicative of increasing or decreasing severity of withdrawal. A CIWA ‐Ar protocol breach was defined as inappropriate administration of benzodiazepines (CIWA ‐Ar < 10) and failure to administer benzodiazepines when required (CIWA ‐Ar ≥ 10). term benzodiazepine use: study protocol of randomized controlled trial Wing-Fai Yeung1, Ka-Fai Chung2*, Zhang-Jin Zhang3, Wai-Chi Chan2, Shi-Ping Zhang4, Roger Man-Kin Ng5, Connie Lai-Wah Chan6, Lai-Ming Ho7, Yee-Man Yu1 and Li-Xing Lao3 Abstract Background: Conventional approaches for benzodiazepine tapering have their limitations. There has been long-term debate over whether fixed or symptom-triggered doses of benzodiazepine could reach better treatment outcome. A maximum of 1 dose of gabapentin (over and above continuation of low-dose home gabapentin ≤900 mg total daily) during their hospitalization was allowed. %PDF-1.6 %���� Which specific scales to use are at program medical director discretion, as long as they are objective and validated. Alcohol Withdrawal Management Protocol - Page 2 of 2. No medication is specifically FDA-approved for the treatment of benzodiazepine dependence. Alcohol Withdrawal Protocol. Instead of thirty different signs, the revised version only has ten symptoms, and can be used to determine the development of alcohol withdrawal syndrome. 4 0 obj Withdrawal Scales •Benzodiazepine Withdrawal Symptom Questionnaire •20 items, scored 0-2 •Self-report •CIWA-B •22 items, scored 0-4 •17 self-report, 3 observation •Mild (1-20), moderate (21-40), severe (41-60), very severe (61-80) 38 Tyrer P, Murphy S, Riley P. The Benzodiazepine Withdrawal … Benzodiazepine (BZDP) agents are the standard for the prophylaxis and treatment of all phases of alcohol withdrawal syndrome. There has been long-term debate over whether fixed or symptom-triggered doses of benzodiazepine could reach better treatment outcome. It has been used effectively as a guidance on benzodiazepine dosing of alcohol withdrawal treatment for decades, 20 we suggested using CIWA-Ar as a tool to evaluate the severity of GHB withdrawal. However, the effects of a protocol combining fixed-schedule and symptom-triggered benzodiazepine dosing are less clear. Evidence for the protocol was supported by recommendations from Reoux and Oreskovich, 12 which included symptomtriggered medication administration based on CIWA-Ar scores. Scores are not directly linked to pharmacological management as occurs with alcohol scores based on the CIWA-Ar. h�b```"3�O� cb�}%���'�e8ڶ�|(�h����@� ���ST����� ��X��Q L���a�b�tP`~�(��y@���u]ZSP��(8�� ��������T ��"@ Typically, a CIWA-Ar protocol may be ordered prophylactically in the emergency department but can be initiated at any point during the hospital stay if alcohol withdrawal is suspected. Monitoring and Protocols. Generally speaking, symptom triggered … But CIWA does not work for benzodiazepine withdrawal. To expedite treatment and ensure reproducibility, the CIWA was revised to the Clinical Institute Withdrawal Assessment-Alcohol-revised (CIWA-Ar), which is a shortened version of the scale. Detox and inpatient or residential treatment centers that incorporate detox protocols are usually the best settings for people who have been taking high daily doses of benzodiazepines, are elderly, and who use benzodiazepines with alcohol. o diazepam 20 mg IV/PO every 1 hour PRN for CIWA-Ar score greater than 19 o diazepam 10 mg IV/PO every 1 hour PRN for CIWA-Ar score greater than 19 o LORazepam 4 mg IV/SL/PO every 1 hour PRN for CIWA-Ar score greater than 19 o LORazepam 2 mg IV/SL/PO every 1 hour PRN for CIWA-Ar score greater than 19 If CIWA-Ar Score 10 to 19 – Moderate agitation - It was developed in 1981, modified in 1989 but hasn’t been challenged since then. If a patient is on multiple benzodiazepines, the equivalent daily doses should be added, and the patient should be started on an equivalent dose of a single long acting agent. Assess current state of withdrawal with CIWA-Ar. %PDF-1.5 Perform baseline CIWA-Ar 2. Sudden cessation of benzodiazepine use; Xanax (alprazolam) use ; High Benzodiazepine doses; You must use a benzodiazepine to treat benzodiazepine withdrawal. The maximum score possible is 40, unless of course additional symptoms are included. Give Thiamine mg IV initially and qd (po, IM/IV), Folate 1mg qd, MVI qd. Use a long acting benzo instead. The maximum score possible is 40, unless of course additional symptoms are included. Alcohol Withdrawal Protocol. A.CIWA <8 and Low Risk. Use Modified CIWA to monitor symptoms hourly for first 12 hours, then if no withdrawals two hourly for second 12 hours –see below to establish initial regular dose after 24hrs. The gabapentin group was comprised of patients who received 2 or more doses of gabapentin (totaling ≥900 mg total … The instrument also has been adapted for benzodiazepine with-drawal assessment (Clinical Institute Withdrawal Assessment-Benzodiazepine). Know the big three predictors of a potentially serious withdrawal syndrome. protocol improves patient outcomes (Repper-Delisi et al. A clinical scale to assess benzodiazepine withdrawal. If score is :�'�X�;�ك�˛�b����?\��3z�dE����F?e�_�MsO�f�.�p��_�Χ����cS���~�Z��p%��:�Jw)�7�����u��|ڪ('�›s/쐹�k�5�;��.R�������Xo]߯�(��B�)�9}4����֠�?��D@�F�\W���-�E����c�׻fr���0($q��gf���{�l]�O�C֑F=�;��T��T��^"2��'՗����lzux���*6�@'�+��F�Z���2��r�����A�L�[���Ū�G���6��h���+�o�z��Qu�-�Z��т�;���%Z�L"�!#��أ�b�� ��H` q�l�%Y����o�W'�:ϊ�`�S�����h�s)���=��|���=�5���յ�������u����yX߯þ6��X���T�|��`���_ݔ9������ �L�f If score is >/=8, return to step 1 in hour >20 4mg PO/IV Reduced dose protocol recommended for elderly(age >65) or frailpatients PEARLs 1. Drug and Alcohol Withdrawal Clinical Practice Guidelines - NSW SummaryTo provide the most up-to-date knowledge and current level of best practice for the treatment of withdrawal from alcohol and other drugs such as heroin, and other opioids, benzodiazepines, cannabis and psychostimulants. exhibiting mild withdrawal (CIWA-Ar score 10 to 20). Treatment of Alcohol Withdrawal Syndrome: Phenobarbital Vs CIWA-Ar Protocol 20 Tidwell et al., 2018 Design Retrospective Cohort Study Objective Compared a symptom-triggered benzodiazepine protocol used in conjunction with the CIWA-Ar scale to a phenobarbital protocol Note also whether the symptoms occurred when the tablets were reduced or stopped, or if the The CIWA scale has well-documented reliability, reproducibility and validity, based on comparison to rating by expert clinicians. Purpose: To assist with early identification and management of the patient at risk for alcohol withdrawal syndrome (AWS) and to prevent negative physical and /or psychosocial consequences of the withdrawal experience. The utilization of CIWA-Ar in such cases could offer useful guidance for benzodiazepine dosing. Alcohol withdrawal severity Per CIWA-Ar scale protocol [ Time Frame: Through study completion, an average 4 days ] Sleepiness as assessed by the Epworth Sleepiness Scale [ Time Frame: At time of enrollment and at discharge, an average of 4 days ] Total amount of benzodiazepines given [ Time Frame: During length of admission, an average of 4 days; or time to CIWA score < 10 for 36 hours ] … The MINDS protocol should be used to manage the spectrum of symptoms that can arise during withdrawal benzodiazepine withdrawal the...: cognitive impairment, most reliable benzo for IM absorption withdrawal Symptom Questionnaire Each moderate score is of... 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