Lead for Gastroenterology Lee Dodge Alcohol Liaison 03/03/2015. Clive Gibson Safeguarding Adults Lead Nurse 03/03/2015

Transcription

1 Acute Alcohol Withdrawal Management for Adult Inpatients Type: Clinical Guideline Register No: 1409 Status: Public on ratification Developed in response to: Best Practice Contributes to CQC Outcome number: 4 Consulted With Post/Committee/Group Date Lauren Jones & Maria Richards Pharmacists 11/0/01 Adele Wisby Head of Nursing 1/01/01 Dr Rakesh Shah Consultant Gastroenterologist & Clinical 0/01/01 Lead for Gastroenterology Lee Dodge Alcohol Liaison 0/0/01 Clive Gibson Safeguarding Adults Lead Nurse 0/0/01 Doug Smale Local Security Management Specialist 0/0/01 Ryan Curtis Health & Safety Manager 0/0/01 Professionally Approved By Dr Alan Jackson Clinical Director Medicine 19/01/01 Version Number 1.1 Issuing Directorate Acute Medicine Ratified by: Document Ratification Group Ratified on: th March 01 Executive Management Board Sign Off April 01 Date Implementation Date 0th March 01 Next Review Date March 018 Author/Contact for Information Dr Chirag Oza, Consultant Gastroenterologist & Hepatologist Policy to be followed by (target staff) All Clinical Staff Distribution Method Intranet & Website Related Trust Policies (to be read in conjunction with) Document Review History Version Number Brief Reason for Change or Update Authored/Reviewed by Active Date 1.0 First version Dr Chirag Oza 0 March Update to 10.1 Maria Richards November 01 1

2 Index 1. Purpose. Scope. Staff Training 4. Definitions. Management first 4 hours. Management after the first 4 hours 7. Difficult to Control Patients 8. Discharge Planning 9. Breech Reporting 10. Audit & Monitoring 11. Useful Contacts 1. References Appendix 1 Clinical Alcohol Withdrawal Assessment (CIWA-Ar) Chart Appendix Dose Calculation

3 1. Purpose 1.1 This purpose of this clinical guideline is to: standardise the prescription of detoxification for alcohol withdrawal in all adult patients admitted with, or experiencing, alcohol withdrawal to minimise morbidity and mortality and maximise patient comfort through:.0 Scope Recognition of all alcohol misuser hospital attendees. Identification of sub-groups with, or at risk of, potentially life-threatening complications. Prompt initiation of appropriate medical management.1 This policy is to be used by all doctors, nurses, pharmacists and Allied Health Professionals.. This policy covers adult inpatients experiencing acute alcohol withdrawal (18 years and above) in Broomfield Hospital. It excludes outpatients.. This policy should be considered in all adult patients at risk of acute alcohol withdrawal, as identified by AUDIT-C in the Nursing Assessment, or identified during medical/surgical clerking at the time of admission (acute or planned). However, the decision for detoxification should be made by a senior doctor who has experience in managing these patients..4 Detoxification from alcohol in inpatients is usually indicated in the following cases: Definitely indicated if weekly alcohol consumption exceeds 100 units/week Probably required for patients drinking 0 to 100 units/week Not usually needed when intake is less than 0 units a week but may be required. Patients with complex alcohol withdrawal (e.g. DTs (delirium tremens), seizures, hallucinations, etc.), should be admitted for inpatient management of alcohol withdrawal as per the guidelines set out in this policy..0 Staff Training.1 All medical and nursing staff are to ensure that their knowledge, competencies and skills are up to date.. During induction, staff will receive instruction on current policies and guidelines and how to access them.. Staff will receive training on how to use this policy on the wards. This will be undertaken as face to face training by the Alcohol Liaison Nurse. This will be mandatory for all doctors and nurses working on wards where patients are admitted for more than 4 hours.

4 4.0 Definitions 4.1 Alcohol withdrawal This refers to a group of symptoms that may occur from suddenly stopping the use of alcohol after chronic or prolonged ingestion Symptoms and signs include (amongst others): Anxiety, agitation, irritability, depression, mood swings, insomnia, tremor of the hands, tongue, eyelids, fever (with or without infection), hypertension, tachycardia, sweating, nausea, vomiting, diarrhoea, headache, pallor, dilated pupils, amongst others. 4. Delirium Tremens 4..1 Delirium tremens (DTs) is the most severe form of alcohol l withdrawal manifested by altered mental status (global confusion) and sympathetic overdrive (autonomic hyperactivity), which can progress to cardiovascular collapse. 4.. DTs occur in about % of patients during withdrawal, usually - days after alcohol cessation or reduced alcohol intake. 4.. DTs are fatal in 1-0% of inappropriately managed patients, whilst prophylactic and proactive sedation reduces mortality to 1-% 4..4 Symptoms and signs include agitation, fever, hallucinations, confusion and seizures 4. Wernicke s Encephalopathy 4..1 This refers to the presence of neurological symptoms caused by biochemical lesions of the central nervous system, after exhaustion of B vitamin reserves, in particular thiamine. 4.. It classically presents with the triad of confusion, ataxia and ophthalmoplegia, but only 10% of patients present with all three features. 4.. It may develop rapidly or over a number of days. Inappropriately managed, it is the primary (or a contributory) cause of death in up to 0% of patients and results in permanent brain damage (Korsakoff s psychosis) in 8% of survivors. 4.4 Alcohol Units One unit equates to 10ml or 8g of pure ethanol The alcohol by volume (ABV) of a drink equates to the number of units contained in one litre of that drink, e.g. a 1 litre bottle of 40% spirit will contain 40 units of alcohol..0 Management first 4 hours.1 Patients who have capacity must consent (verbally) to the alcohol detoxification regime. If they are not consenting, urgent senior clinician review is necessary to ascertain appropriateness of admission. For those patients who do not have capacity to consent, an MCA will need to be filled out, and consideration for DoLS (deprivation of liberty) made if indicated.. For the first 4 hours of the admission (initial assessment and treatment) the admitting doctor (FY1/FY/CT/SpR/Consultant) should prescribe the following: Adults < yrs with no co-existing risk factors*: chlordiazepoxide -0mg PO - 4 hourly PRN as per CIWA-Ar chart (maximum 0mg in 4 hours) 4

5 Elderly (age > yrs) or in presence of co-existing risk factors*: chlordiazepoxide 10 mg -4 hourly PRN (maximum 0mg in 4 hours) *co-existing risk factors are liver impairment, frailty, renal impairment, concomitant opioids Pabrinex I+II, pairs (= 4 vials) IV TDS for days Thiamine 100mg PO BD for 0 days, after completion of IV Pabrinex Vitamin B Co. Strong tabs PO OD for 0 days, after completion of IV Pabrinex Diazepam 10-0mg (elderly 10mg) IV/PR PRN for seizures (patients are at risk of withdrawal seizures. Nurses are to assess the patient for the first 4 hours using a flexible regime via CIWA- Ar Withdrawal Scale (See Appendix 1.1 CIWA-Ar Assessment Tool), and administer chlordiazepoxide as follows: CIWA-Ar score Adults <yrs with no co-existing risk factors* Treatment Adults yrs and/or with co-existing risk factors* 0-9 (mild withdrawal) (moderate withdrawal) >1 (severe withdrawal) ASSESS CIWA-Ar EVERY -4 HOURS No treatment necessary Administer chlordiazepoxide mg STAT (then give mg every -4 hours PRN. Maximum daily dose of 0mg in 4 hours) Administer chlordiazepoxide 0mg STAT (then give 0mg every -4 hours PRN. Maximum daily dose of 0mg in 4 hours) ASSESS CIWA-Ar HOURLY No treatment necessary Administer chlordiazepoxide 10mg STAT (then give 10mg every -4 hours PRN. Maximum daily dose of 0mg in 4 hours) Administer chlordiazepoxide mg STAT (then give mg every -4 hours PRN. Maximum daily dose of 0mg in 4 hours) *co-existing risk factors are liver impairment, frailty, renal impairment, concomitant opioids.4 Patient should be assessed more frequently if scores remain high despite treatment, or if patient clinically appears to still be withdrawing. If patient is pregnant, ensure Obstetric team have been notified of admission.0 Management after the first 4 hours.1 After the first 4 hours, stop the chlordiazepoxide prescribed on a PRN basis.. Calculate total chlordiazepoxide administered during the first 4 hours and start a regular reducing regime accordingly.. Reduce the total dose needed in 4 hours by 0%, then divide this dose into 4 equal doses and prescribe as a fixed QDS dose for the detoxification regime..4 Continue to reduce the total daily dose by 0% daily over the following -7 days, and then stop the chlordiazepoxide (this is as an inpatient).

6 . Assess patient as per CIWA-Ar withdrawal scale every 4 hours. Review patients daily. A sign that the patient is receiving the right dose is that the CIWA scores should be reducing over time.. Patients should not normally be prescribed PRN chlordiazepoxide after the initial 4 hours. A patient who is still showing withdrawal symptoms and may need further PRN should be assessed and their detoxification regime reviewed. A patient who seems oversedated after first 4 hours should also have the reducing regime reviewed by review team. 7.0 Difficult to Control Patients 7.1 These patients should be urgently reviewed by Medical Staff. Consider switching to IV diazepam may be administered as a bolus at a rate of mg/min through a peripheral (large vein) or central route. A dose of -10mg every 0-0mins may be given until symptoms subside or the patient is sedated (max 0mg in 4hours). These patients should be managed either on MHDU or ITU. 7. In elderly patients use half the recommended diazepam dose. Beware of airway and respiratory complications. 7. For patients with liver failure, IV lorazepam 1-mg over mins (max hourly) may be used instead of diazepam (allowing for drug availability). 7.4 Consider using haloperidol PO/IM mg TDS as an alternative option 7. Consider extending the PRN dosing beyond 4hours in patients with delirium tremens 7. Consider using a longer withdrawal regimen if unable to stabilise after 4 hours 7.7 Discuss with the senior medical team and consider consulting with Psychiatric Liaison. 7.8 Strict cardiac & airways monitoring is essential. If this cannot be achieved then avoid IV sedation 7.9 Patients who are agitated or violent secondary to delirium tremens may require the presence of hospital security to ensure their own, other patient s, visitors and staff safety. In an emergency situation security are to be contacted using the bleep system. If long term security is required this is to be arranged with the Trust Security Manager, with advice as to what may be required from the LSMS (Local Security Management Specialist). 8.0 Discharge Planning 8.1 The detoxification regimen should be completed before the patient is discharged. 8. Make it clear on the prescription chart that chlordiazepoxide stops after the last day of the detoxification regime 8. At Consultant s discretion, patients can be given up to a maximum of 0mg chlordiazepoxide in discharge medication. Please specify it is not to be continued after this. 8.4 Patients who discharge themselves against medical advice should not be supplied with chlordiazepoxide to take away, and they should sign the Trust self discharge form. 8. All patients undergoing detoxification should be discharged on thiamine 100mg twice daily and Vitamin B Co Strong tabs daily for 0 days.

7 8. It is important that the GP is informed on the discharge letter not to add chlordiazepoxide to patients repeat medications. 9.0 Breech Reporting 9.1 Those patients who come to harm (withdrawal seizure, DTs, etc.) during their admission will require a Datix completed Audit & Monitoring 10.1 Pharmacy will monitor all acute prescriptions for chlordiazepoxide, and any concerns will be reported to the physician responsible for the patient. 10. Annual audit will be undertaken to monitor patient length of stay and any adverse events. This will be undertaken by the Gastroenterology department, and presented at one of the weekly Gastroenterology teaching sessions. 10. All reported (datixed) risk events will be reviewed at least annually and the Consultant Gastroenterologist & Hepatologist will report any findings/trends to the Clinical Director Useful Contacts Lee Dodge, Alcohol Liaison Nurse: Ext 4804, Mobile lee.dodge@meht.nhs.uk CHANGES (Community Drug & Alcohol Team) Tel: CHOICES Chelmsford (OpenRoad) Tel: Essex Young People s Drug and Alcohol Services (EYPDAS) Tel: References Taylor, D; Paton, C; Kerwin R (007). The Maudsley Prescribing Guidelines 9th Edition BNF. September 01 NICE guidelines: Alcohol-use disorders: physical complications (June 010) NICE guidelines: Nutrition support in adults (November 01) Parker AJ, Marshall EJ, Ball DM; Diagnosis and management of alcohol use disorders. BMJ. 008 Mar 1; (74): Health and Social Care Information Centre: Appendix 1 7

8 Clinical Alcohol Withdrawal Assessment (CIWA-Ar) Chart This chart is to be used in conjunction with the assessment questions overleaf Frequency of s: Hourly 4 Hourly Surname (or affix label): Ward: Forename(s): Date of Birth: Hospital Number: Consultant: NHS Number: Date Time Assess and rate each of the following: Nausea/Vomiting (0-7) Tremors (0-7) Paroxysmal Sweats (0-7) Anxiety (0-7) Agitation (0-7) Tactile Disturbances (0-7) Auditory Disturbances (0-7) Visual Disturbances (0-7) Headache (0-7) Orientation (0-7) Total CIWA-Ar Score Dose given (mg) Please sign drug chart If CIWA-Ar = Give mg Chlordiazepoxide If CIWA-Ar = 1 Give 0mg Chlordiazepoxide Nurse Signature Using the descriptions and questions overleaf, rate each withdrawal symptom, then add the scores together Nausea and Vomiting: Ask Do you feel sick to your stomach? Have you vomited? Tactile (touch) Disturbances: Ask Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling 8

9 0 no nausea with no vomiting 1 mild nausea with no vomiting 4 intermittent nausea with dry heaves 7 constant nausea, frequent dry heaves and vomiting Tremor: Arms extended and fingers spread wide apart. 0 no tremor 1 not visible, but can be felt fingertip to fingertip 4 moderate, with patients arms extended 7 severe, even with arms not extended Paroxysmal Sweats: 0 no sweat visible 1 barely perceptible sweating, palms moist 4 beads of sweat obvious on forehead 7 drenching sweats Anxiety: Ask Do you feel nervous? 0 no anxiety, at ease 1 mildly anxious 4 moderately anxious or guarded, so anxiety is suggested 7 equivalent to acute panic states as seen in severe delirium or acute schizophrenic states Agitation: 0 normal activity 1 somewhat more than normal activity 4 moderately fidgety and restless 7 paces back and forth during interview, or thrashes about on or under your skin? 0 none 1 very mild itching, pins and needles, burning or numbness mild itching, pins and needles, burning or numbness moderate itching, pins and needles, burning or numbness 4 moderately severe hallucinations severe hallucinations extremely severe hallucinations 7 continuous hallucinations Auditory (hearing) Disturbances: Ask Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing you? Are you hearing things you know are not there? 0 not present 1 very mild harshness or ability to frighten mild harshness or ability to frighten moderate harshness or ability to frighten 4 moderately severe hallucinations severe hallucinations extremely severe hallucinations 7 continuous hallucinations Visual (sight) Disturbances: Ask Does the light appear to be too bright? Is it s colour different? Does it hurt your eyes? Are you seeing anything that s disturbing you? Are you seeing anything that you know is not there? 0 not present 1 very mild sensitivity mild sensitivity moderate sensitivity 4 moderately severe hallucinations severe hallucinations extremely severe hallucinations 7 continuous hallucinations Headache, Fullness in Head: Ask Does your head feel different? Does it feel like there is a band around your head? Do not rate for dizziness or lightheadedness. Otherwise, rate severity. 0 not present 1 very mild mild moderate 4 moderately severe severe very severe 7 extremely severe Orientation and Clouding of Sensorium: Ask "What day is this? Where are you? Who am I?" 0 orientated and can do serial additions 1 cannot do serial additions or is uncertain about date disorientated for date by no more than calendar days disorientated for date by more than calendar days 4 disorientated for place or person Appendix 9

10 DOSE CALCULATION Simple Dose Equivalence: Diazepam 10 mg = chlordiazepoxide mg = lorazepam 1mg Chlordiazepoxide dose calculation after 4 hours: After the first 4 hours, stop the chlordiazepoxide prescribed on a PRN basis. Calculate total chlordiazepoxide administered during the first 4 hours and start a regular reducing regime accordingly. Reduce the total dose needed in 4 hours by 0%, then divide this dose into 4 equal doses and prescribe as a fixed QDS dose for the detoxification regime Continue to reduce the total daily dose by 0% daily over the following -7 days, and then stop the chlordiazepoxide (this is as an inpatient). Chlordiazepoxide should not been administered at the same time as other benzodiazepines (e.g. diazepam and lorazepam), but if other benzodiazepines have been given, the equivalent separate doses should be added to calculate the 4 hour total dose EXAMPLE DOSE CALCULATOR Record dose and time of any benzodiazepine (eg. chlordiazepoxide) given in 4 hour period Continue to reduce the total daily dose by 0% daily over the following -7 days, and then stop the chlordiazepoxide DATE AND TIME CIWA SCORE BENZODIAZEPINE GIVEN DOSE ADMINISTERED (mg) Total dose of Benzodiazepines at 4 hours NB: Convert other benzodiazepines to equivalent dose of chlordiazepoxide [Total dose reduced by 0%] [Total dose reduced by 0%} divided by 4 = QDS dose for next day 10