BMs The Clinical Institute Withdrawal Assessment Alcohol (CIWA-Ar, see page 4-6)

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1 Alchl Withdrawal Guideline Intrductin As a Trust, it is vital we mnitr patients with knwn alchl dependence clsely. Nt ding s can result in serius and life threatening cmplicatins such as withdrawal and cmplicatins such as delirium tremens (DT), seizures r Wernicke s encephalpathy. Recgnising Key Symptms Alchl withdrawal cmmnly appears between -7 hurs after last alchl use. Risk factrs fr severe withdrawal include: - High alchl Intake (>1 units a day) - Previus histry f severe withdrawal/seizures/dts - Use f psychtrpic drugs and/r substances f misuse - Pr physical health - High level f anxiety - Fever/sweating/tachycardia - Insmnia Symptms f active withdrawal include: Mild Mderate Severe Mild anxiety Marked anxiety Marked anxiety and increasing cnfusin Insmnia Insmnia and irritability Insmnia and irritability Slight sweating Prfuse sweating Prfuse sweating Tachycardia (>100) Tachycardia (>100) Tachycardia ( >10) Fever (>7) Fever (>7) Fever (>7) Nausea, vmiting and diarrhea Raised BP Raised BP Restlessness and tremr Hallucinatins and delusins Lss f balance Cnvulsins Unsteady walk cmpared t befre (ataxia) Investigatins Observatins (BP, pulse, temperature) - three times a day. Alchl intake & time f last drink Blds Full bld cunt: anaemia, hazardus drinking (raised MCV) Urea & electrlytes: ptassium must be checked if there is arrhythmia Liver functin tests assess severity f liver disease Cltting functin (e.g. INR) disrupted in liver failure Thyrid functin a differential diagnsis f arrhythmia Magnesium & phsphate refeeding syndrme ECG Level bservatins Alchl Withdrawal Guideline Page 1 f 7 Versin 1.0 September 018

2 BMs The Clinical Institute Withdrawal Assessment Alchl (CIWA-Ar, see page 4-) Fixed dse reductin regimen Chlrdiazepxide is the benzdiazepine used in the majrity f centres fr patients with alchl withdrawal. It is cnsidered t have a lw dependence-frming ptential, if the patient has significant hepatic impairment/liver failure then a shrt acting benzdiazepine is preferred e.g. lrazepam (1mg lrazepam apprximately equivalent t mg f chlrdiazepxide). Ensure patient is nt prescribed ther ral benzdiazepines (fr agitatin) alng with chlrdiazepxide. Assess the severity f alchl withdrawal using CIWA-Ar (see pg 4-), based n the scre determine severity f dependence and therefre the fixed dse regime required (see table belw). If still intxicated d nt prescribe benzdiazepines. If elderly cnsider halving the dses f chlrdiazepxide CIWA- Ar < >0 Severity f Mild Mderate Mderate-Severe Severe Dependence (treatment nt required) (treatment may nt be required) Starting Dse f 0 mg 0mg 40mg Chlrdiazepxide Day 1mg mg mg Day 10mg 0mg 0mg Day 4 mg 1mg mg Day mg BD 10mg 0mg Day 10mg BD 1mg Day 7 mg BD 10mg Day 8 10mg TDS Day 9 10mg BD Day 10 mg BD PRN Chlrdiazepxide 10-0mg shuld be written up with a maximum f 0mg/day including regular. Patients shuld nt be discharged n chlrdiazepxide unless under the care f an fficial alchl withdrawal scheme. Thiamine supplementatin Prphylaxis f Wernicke- Krsakff syndrme Alchl withdrawal seizures Oral likely t be sufficient - Thiamine 0mg Pabrinex IM 1 pair OD fr day Day discharge Thiamine 0mg Pabrinex IM 1 pair OD fr days Day discharge Thiamine 0mg Diazepam 10mg PR Pabrinex IM 1 pair OD fr days Day discharge Thiamine 0mg Alchl Withdrawal Guideline Page f 7 Versin 1.0 September 018

3 Mnitr CIWA-Ar Scre daily: 1) If the scre decreases, cntinue with reducing regimen ) If the scre remains the same r increases, cnsider reverting back t previus dse r increase accrding t scre severity. Vitamins Preventin f Wernicke-Krsakff Syndrme Pabrinex Intramuscular High Ptency (IMHP). 1 pair f ampules ONCE a day fr days. The cntents f each pair f ampules shuld be drawn up int a syringe t mix just befre use and injected slwly. Recrd BP and pulse befre and after giving Pabrinex. SITE OF INJECTION: HIGH INTO THE GLUTEAL MUSCLE CM BELOW THE ILIAC CREST. Als give ral supplementatin f thiamine 0mg nce the curse f Pabrinex is cmpleted. On discharge lwer t Thiamine 0mg BD. IM PABRINEX HAS A LOWER INCIDENCE OF ANAPHYLACTIC REACTIONS THAN IV AND THE RISK REMAINS LOW HOWEVER FACILITIES FOR TREATING ANAPHYLAXIS REACTIONS SHOULD BE PRESENT. Cmplicatins 1) Delirium Tremens - Mrtality risk f up t 0% if unrecgnised. - Clinical features include cnfusin and disrientatin, severe tremr, sweating, fluctuating BP and pulse, visual and auditry as well as delusinal beliefs. - Cnsider transfer t acute hspital urgently. ) Wernicke s Encephalpathy - Mrtality risk f up t 1% if unrecgnised and can result in permanent brain damage (Krsakff s psychsis). - Clinical features include acute cnfusin, ataxia and paralysis f eye muscles ccurs in 10% f patients. Other features include unexplained hyptensin and hypthermia, memry disturbance and unsteadiness. - Cnsider transfer t acute hspital urgently fr IV Pabrinex. ) Withdrawal Seizures - Manage with 10mg rectal diazepam. - RING 999 Alchl Withdrawal Guideline Page f 7 Versin 1.0 September 018

4 CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT FOR ALCOHOL (CIWA-Ar) NAUSEA AND VOMITING Ask D yu feel sick t yur stmach? Have yu vmited? Observatins. 0 n nausea and n vmiting 1 mild nausea with n vmiting 4 intermittent nausea with dry heaves 7 cnstant nausea, frequent dry heaves and vmiting TREMOR Arms extended and fingers spread apart. Observatins 0 n tremr 1 nt visible, but can be felt fingertip t fingertip 4 mderate, with patient s arms extended 7 severe, even with arms nt extended PAROXYSMAL SWEATS - Observatin 0 n sweat visible 1 barely perceptible sweating, palms mist 4 beads f sweat bvius n frehead 7 drenching sweats ANXIETY Ask D yu feel nervus? Observatin. 0 n sweat visible 1 barely perceptible sweating, palms mist 4 beads f sweat bvius n frehead 7 equivalent t acute panic states as seen in severe delirium r acute schizphrenic reactins AGITATION Observatin 0 nrmal activity 1 smewhat mre than nrmal activity 4 mderately fidgety and restless 7 paces back and frth during mst f the interview, r cnstantly thrashes abut TACTILE DISTURBANCES Ask Have yu any itching, pins and needles sensatins, any burning, any numbness, r d yu feel bugs crawling n r under yur skin? Observatin. 0 nne 1 mild nausea with n vmiting mild itching, pins & needles, burning & numbness mderate itching, pins & needles, burning r numbness 4 mderately severe severe extremely severe 7 cntinuus AUDITORY DISTURBANCES Ask Are yu mre aware f sunds arund yu? Are they harsh? D they frighten yu? Are yu hearing anything that is disturbing t yu? Are yu hearing things yu knw are nt there? Observatin. 0 nt present 1 very mild harshness r ability t frighten mild harshness r ability t frighten mderate harshness r ability t frighten 4 mderately severe severe extremely severe 7 cntinuus VISUAL DISTURBANCES Ask Des the light appear t be t bright? Is its clr difference? Des it hurt yur eyes? Are yu seeing anything that is disturbing t yu? Are yu seeing things yu knw are nt there? Observatin. 0 nt present 1 very mild sensitivity mild sensitivity mderate sensitivity 4 mderately severe severe extremely severe 7 cntinuus HEADACHE, FULLNESS IN HEAD Ask Des yur head feel different? Des it feel like there is a band arund yur head? D nt rate fr dizziness r lightheadedness. Otherwise, rate severity. 0 nt present 1 very mild mild mderate 4 mderately severe severe very severe 7 extremely severe ORIENTATION AND CLOUDING OF SENSORIUM Ask What day is this? Where are yu? Wh am I? 0 riented and can d serial additins 1 cannt d serial additins disriented fr date by n mre than calendar days disriented fr date by mre than calendar days 4 disriented fr place/r persn Alchl Withdrawal Guideline Page 4 f 7 Versin 1.0 September 018

5 SCORES NAME: DOB: 0-9: MILD WITHDRAWAL SURNAME: NHS NO: 10-19: MODERATE WITHDRAWAL (CONTACT DOCTOR) >0: SEVERE WITHDRAWAL (CONTACT DOCTOR URGENTLY) CIWA-Ar Scre Table Cmplete n initiatin and at least daily thereafter as required ADDRESS: CIWA-Ar scre increases, alert dctr. Symptms Nausea (0,1,4,7) Tremr (0,1,4,7) Sweats (0,1,4,7) Anxiety (0,1,4,7) Date/Time Agitatin (0,1,4,7) Tactile Hallucinatins (0-7) Auditry Hallucinatins (0-7) Visual Hallucinatins (0-7) Headache (0-7) Orientatin (0-4) Ttal Scre Nurse/Dctr Signature Alchl Withdrawal Guideline Page f 7 Versin 1.0 September 018

6 CIWA-Ar Scre with Reference Scres Nausea/Vmiting NONE Mild nausea, n vmiting Tremr Sweats NONE NONE Nt visible, but can be felt fingertip t fingertip Barely sweating, palms mist Anxiety NONE Mild anxiety Intermittent nausea with dry heaves Mderate, with patient s arms extended Sweat n frehead Mderately anxius, r guarded Cnstant nausea, frequent dry heaves & vmiting Severe, even with arms nt extended Drenching sweats Equivalent t acute panic states Agitatin NONE Mre than nrmal activity Mderately restless Paces back and frth Tactile Hallucinatins Auditry Hallucinatins NONE Very mild itching, pins and needles, burning r numbness Mild itching, pins and needles, burning r numbness Mderate itching, pins and needles, burning r numbness NONE Very mild Mild Mderate Visual Hallucinatins NONE Very mild Mild Mderate Mderately severe Mderately severe Mderately severe Severe Severe Severe Extremely severe Extremely severe Extremely severe Cntinuus Cntinuus Cntinuus Headache NONE Very mild Mild Mderate Mderately severe Severe Very severe Extremely severe Orientatin NONE Uncertain f date Incrrect date < days Incrrect date > days Disriented fr place/persn Alchl Withdrawal Guideline Page f 7 Versin 1.0 September 018

7 Bibligraphy Taylr, D. Patn, C. Kapur, S. The Maudsley Prescribing Guidelines. 1 th Editin. Wiley Blackwell. Chichester; 01. Natinal Institute f Clinical Excellence (011). Alchl-use disrders: diagnsis, assessment and management f harmful drinking and alchl dependence. NICE clinical guideline CG11. Lingfrd-Hughes AR, Welch S, Peters L, et al. BAP updated guidelines: evidence-based guidelines fr the pharmaclgical management f substance abuse, harmful use, addictin and cmrbidity: recmmendatins frm BAP. Jurnal f Psychpharmaclgy 01. Guidelines written by BCPFT Pharmacy Team: September 018 Next Review Date: Sept 01 Alchl Withdrawal Guideline Page 7 f 7 Versin 1.0 September 018