Management and Treatment Guidelines For Acute Alcohol Withdrawal Policy

Management and Treatment Guidelines
For
Acute Alcohol Withdrawal Policy
November 2009
1
Title
Management and Treatment Guidelines for Acute Alcohol
Withdrawal Policy
Reference Number
Acute10/001
Implementation Date
November 2009
Review Date
August 2011 or earlier if required
Responsible Officer
Maeve Brown
2
Table of contents
1. Introduction
2. Establish a comprehensive alcohol history
3. Carry out essential investigations
4. Be wary of and treat any complications
5. Assess the severity of withdrawal using the CIWA-Ar scale
6. Risk factors for progression to severe AWS/DTs
7. Prescribing benzodiazepines
8. Prescribing Thiamine
9. Monitoring requirements
10. Interpreting changes in the CIWA-Ar score
11. Managing breakthrough symptoms
12. Severe/uncontrolled withdrawal symptoms
13. Seizures
14. Patient’s ‘Nil by mouth’
15. Discharge
16. Useful numbers
References
Appendix 1: WHSCT Alcohol Detoxification Care Pathway
Appendix 2: PAT tool
Appendix 3: AUDIT tool
Appendix 4: CIWA-Ar chart
Appendix 5: Example reducing chlordiazepoxide regimen
Appendix 6: Treatment algorithm for Alcohol Withdrawal Syndrome
Appendix 7: Treatment algorithm for Wernicke’s Encephalopathy
Appendix 8: Benzodiazepine equivalence chart
Appendix 9: The Administration of Chlordiazepoxide
3
Glossary
AUDIT:
Alcohol Use Disorders Identification Test (AUDIT) (appendix 3). A simple tool
used to detect alcohol problems experienced within the last year. The test
contains 10 multiple choice questions on quantity and frequency of alcohol
consumption, drinking behaviour and alcohol-related problems or reactions.
PAT:
Paddington Alcohol Test (PAT) (appendix 2). PAT is an evolving pragmatic
clinical tool that detects alcohol misuse early on in a drinker’s natural history.
PAT is non-judgemental, enabling patients to develop insight into their drinking,
its cause and effect.
CIWA-Ar:
Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar
(appendix 4) is a guide to measuring the severity of alcohol withdrawal
symptoms and in turn affords some guidance to the amount of benzodiazepine to
give.
AWS:
Alcohol Withdrawal Syndrome
DTs:
Delirium tremens
Prepared and submitted to Drugs & Therapeutic Committee WHSCT by:
Dr Neil Black, Consultant Physician, AMU, Altnagelvin Hospital
Claire Crossan, Alcohol Liason Specialist Nurse, Altnagelvin Hospital
Carmel Darcy, Senior Pharmacist, AMU, Altnagelvin Hospital.
4
1. Introduction
Northern Ireland and particularly the Western Trust has a high prevalence of alcohol dependence and
alcohol-related illness. Alcohol withdrawal syndrome (AWS) can and should be managed within the
community when this is feasable. Equally, there are individuals for whom community detoxification
would pose a high risk of complications and who require inpatient medical input.
These guidelines are based on UK and international national publications as examples of evidencebased best practice and professional consensus where the evidence base is limited. This policy aims
to help identify patients who can be managed in the community and those who will require inpatient
care. The treatment guidelines are intended for sue within the acute hospitals of this Trust, but may
be used to help guide management in other clinical areas.
Failure to consider alcohol misuse as an underlying diagnostic possibility may constitute negligence
(Powers 2000), whilst failure to identify and manage potentially serious withdrawal complications
leads to legal liability and awarding of damages (Cook 2000).
Goals: To minimise morbidity and mortality and maximise patient comfort through:
Recognition of all alcohol misuser hospital attendees
Identification of sub-groups with, or at risk of, potentially life threatening complications
Prompt initiation of effective medical management
Alcohol Withdrawal Syndrome: Symptoms are variable in intensity, usually occur within 6 to 8
hours from the last drink, can develop before the blood alcohol level has fallen to zero, then peak
within 24 to 48 hours and last for 3-5 days. In most alcohol dependent patients symptoms are mild to
moderate.
Characteristic Features of Alcohol Withdrawal
EARLY
Mild acute tremulousness, head, hands, legs, trunk
Nausea, retching, sweating
Misperceptions, hallucinations (occur after 24 - 48hrs)
Agitation “must leave hospital”, insomnia
Disorientation in time and place
Clouding of consciousness, impairment of recent memory
LATE
Autonomic Disturbance (fever, tachycardia, hypertension)
SEVERE
Seizures, tend to be generalised (occur within 12 - 48hrs, at least 50% of those with
alcohol-related seizures will develop alcohol withdrawal syndrome with
continued abstinence from alcohol)
DTs (Hallucinations, confusion, disorientation, agitation, tachycardia, fever and
hypertension) (occur after 2-5 days)
Morbidity and mortality: Failure to elicit alcohol misuse even that which is ‘less obvious’ can result
in two potentially life threatening complications:
1. Delirium tremens (DTs) occurs in about 5% of patients during withdrawal, usually 2-5 days
after alcohol cessation or decreased intake and represents a medical emergency. DTs is
fatal in 15-20% of inappropriately managed patients, whilst appropriate prophylactic sedation
reduces mortality to 1-5%.
5
2. Wernicke’s encephalopathy (WE) has been shown to occur in 12.5% of alcohol misusers. It
may develop rapidly or over a number of days. Inappropriately managed it is the primary or a
contributory cause of death in 17% of patients and results in permanent brain damage
in 85% of survivors.
3. WE is initially reversible with parenteral B-vitamins so treatment should be initiated
immediately a diagnosis is suspected or risk factors identified.
Patients presenting to A&E within the WHSCT with evidence of alcohol withdrawal should be
managed as described in the Alcohol Detoxification Care Pathway (Appendix 1).
2. Establish a comprehensive alcohol history:
Date and time of last drink
Units of alcohol consumed per day/week
Drinking pattern i.e. daily/continuous or episodic/binge drinking (consider accuracy of selfreporting)
Previous episodes of alcohol withdrawal
The PAT tool (appendix 2) or AUDIT tool (appendix 3) can be used to establish a
comprehensive history.
3. Carry out the following essential investigations:
Full Blood Picture
Renal function / Electrolyte Profile, Magnesium, Phosphate and Calcium
Liver profile (Treatment with sedatives should not be delayed whilst awaiting results)
Coagulation screen
Serum glucose
Serum ethanol
4. Be wary of and treat any complications which may need managed:
Dehydration and Electrolyte depletion
o both are likely in those who are withdrawing from prolonged alcohol binges
o the degree of dehydration and electrolyte deficiency may be profound and require
substantial replacement (particularly potassium, magnesium and phosphate).
o dehydration and volume depletion increase autonomic activity and contribute to the
physiological challenge posed by AWS
o crystalloid fluids containing potassium at standard maintenance rates are necessary
while the patient is sedated and not ingesting normal fluid intake
o fluids may need to be given at an accelerated rate initially depending on estimates of
haemodynamic compromise, dehydration and serum electrolyte levels. Caution should
be exercised where there is suspicion, or evidence, of decompensation of liver or
cardiac function.
6
o Sodium chloride 0.9% should be given initially to replete electrolytes and fluid. Glucose
5% should be reserved until after haemodynamic stability is achieved and IV thiamine
(Pabrinex®) is given.
Hypoglycaemia
o IV thiamine (Pabrinex®) should always be given before IV glucose administration
Alcoholic ketoacidosis
o Effectively starvation ketosis due to carbohydrate depletion. Contributes to illness and
physiological instability. Low pH with raised serum or capillary ketones (betahydroxybutyrate). Treated after initial high-dose Pabrinex® infusion with 5% dextrose
and KCl.
Delirium caused by alternative causes such as infection, aspiration or head injury
Complications such as liver failure, subarachnoid haemorrhage and GI bleeding can occur in
these patients. Additional investigations may be required.
Early referral of all patients to the Alcohol Liaison Services is essential.
5. Assess the severity of withdrawal using the CIWA-Ar scale and consider any
risk factors:
The CIWA-Ar scale (Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised) (appendix
4) is a guide to measuring the severity of alcohol withdrawal symptoms and in turn affords some
guidance to the amount of benzodiazepine to give. The scale takes less than 5 minutes to complete.
It is not always necessary to ask the patient all 10 questions as observations will often be sufficient to
rate symptoms. The maximum possible score is 67.
The patient’s score can then be used in guiding the amount of benzodiazepine to give, in order to
control symptoms and ultimately prevent progression to delirium tremens.
In addition to the patient’s score, the presence of any risk factors for progression to severe
withdrawal and DTs must be considered.
Assess the patient and rate each of the 10 criteria
Add the score for each criterion to give the patient’s total CIWA-Ar score
Identify if one or more risk factors for progression to DTs are present
CIWA-Ar Score
Suggested Treatment (see section 7/appendix 5)
Withdrawal
Treatment not usually required, commence suggested
treatment if one or more risk factors present
<10
Mild
Commence treatment
10 – 15
Moderate
> 15
Severe
Commence treatment
7
6. Risk factors for progression to severe AWS/DTs:
History
High alcohol intake (>20 units/day)
Insomnia
History of severe withdrawal/DTs or withdrawal seizures
Other psychiatric disorders
Multiple substance addiction/Deliberate self poisoning
Significant physical co-morbidity
Examination
High levels of anxiety / confusion
Fever or sweating
Tachycardia
Signs suggestive of Wernicke’s encephalopathy (see section 8/ appendix 7)
Investigations
Hypokalaemia
Hypoglycaemia
Respiratory alkalosis
8
7. Prescribe benzodiazepine and thiamine treatment as soon as possible after
admission:
Chlordiazepoxide is the drug of choice for alcohol withdrawal due to its longer half life (less risk of
rebound symptoms), lower abuse potential and resale value.
Use reduced doses or switch to lorazepam (equivalence table appendix 8) in the presence of
significant liver impairment.
It is important to avoid either under-treatment, which may lead to DTs or seizures or over treatment,
associated with excess sedation, aspiration, hypotension and paradoxical agitation. The overall
therapeutic aim with prescribing benzodiazepines is to achieve light sedation, which may be defined
as light sleep from which the patient can be easily aroused.
Record the baseline CIWA-Ar, EWS score and consider any additional risk factors
Prescribe the recommended regular and PRN treatment doses for stabilisation.
Treatment is recommended when serum ethanol level is <100mg/100ml and falling. Falling
implies two successive levels. Ideally treatment should commence 6-8hrs after the last drink
or when serum ethanol is zero or close to it.
Severity of withdrawal
Mild
Moderate
Severe
CIWA-Ar score
<10
10-15
>15
Chlordiazepoxide stabilisation
dose
A&E / Day 1
10 to 20mg qds
+ PRN
20 to 30mg qds
+ PRN
40mg stat, repeated
every hour up to three
doses or until
CIWA-Ar <10, then 40mg
qds
Breakthrough PRN
10mg 2hrly
20mg - 30mg 2hrly
30mg - 40mg hrly
Prescribe the first dose as a stat and administer immediately.
Lower doses than those suggested may be considered in patients over 75yrs, females, and
those with respiratory disease, renal impairment and significant liver impairment.
Patients on regular doses of benzodiazepine prior to admission should be continued on the
same in addition to the chlordiazepoxide reducing dose.
Suspected significant liver impairment can be defined as any one of the following,
although many of these features are neither sensitive for nor specific for significant
liver impairment and the full clinical context should be considered:
Previously diagnosed chronic liver disease.
Clinically evident liver disease (jaundice, ascites, hepatic encephalopathy, spider
naevi, palmar erythema, hepatomegaly, or other clinical stigmata of cirrhosis)
L Serum bilirubin, M albumin, L prothrombin time
9
Suggested reduced dosing regimen in presence of significant liver impairment
CIWA-Ar score
<10
10-15
>15
Stabilisation dose
A&E / Day 1
10mg qds
+ PRN
20mg qds
+ PRN
Breakthrough PRN
10mg 2hrly
10-20mg 2hrly
30mg stat, repeated
every 2 hrs up to three
doses or until
CIWA-Ar <10, then 30mg
qds
20-30mg hrly
Review and titrate the prescribed dose against the severity of withdrawal on a daily basis.
Stabilization may need to be prolonged for up to the first three days.
Steady state of blood chlordiazepoxide levels occur after 3 days on average and sedation
requirements during AWS fall with time, therefore the dose should be reduced on a daily basis
or held at higher dose for longer periods than used in the standard schedule if the clinical
state of the patient is slow to settle.
Doses are usually reduced within 48 hours (and should never be reduced in the first 24
hours).
When is medication for alcohol withdrawal inappropriate? (SIGN 74, 2003)
Cessation of alcohol consumption is unlikely to result in withdrawal syndrome in mild
dependence.
Medication to prevent withdrawal may not be necessary if:
o the patient reports alcohol consumption
<15 units/day in men
<10 units/day in women
o and reports neither recent withdrawal symptoms nor recent drinking to
prevent withdrawal symptoms
o the patient has no alcohol on breath test and no withdrawal signs / symptoms
o among binge/periodic drinkers whose last bout was < 1 week long,
medication is seldom needed unless drinking was in excess of 20 units / day
If medication is not given, patients should be informed that they may experience
nervousness/anxiety and insomnia for up to 1 week.
8. Prescribing Thiamine
All patients admitted for alcohol withdrawal should receive IV thiamine (Pabrinex®) and dosed
depending on the severity of withdrawal and or confirmed/imminent Wernicke’s Encephalopathy (WE)
(appendix 7).
10
IV thiamine (Pabrinex®) should always be given before IV glucose administration
CSM warning: IV treatment to be given only when it is essential. Facilities for treating
anaphylaxis should be available when administered
Severe withdrawal/DTs or confirmed/imminent Wernicke’s Encephalopathy (WE)
Consider WE, if one or more of the following symptoms present:
Acute Confusion, decreased consciousness level including unconsciousness / coma
Memory disturbance, Ataxia / unsteadiness, ophthalmoplegia, nystagmus
Unexplained hypotension with hypothermia
High dose IV Thiamine (Pabrinex®)
Dose
Frequency
2 x pairs (amps 1 and 2)
Three times
daily
Route
Duration
IV infusion over
30mins in 100mls
of sodium chloride
0.9%
3 days
Followed by:
IV infusion over
30mins in 100mls
of sodium chloride
0.9%
Followed by oral thiamine 100mg three times daily indefinitely
1 x pair (amps 1 and 2)
Daily
3 -5 days or until
clinical improvement
ceases
Mild withdrawal/risk factors for progression to DTs/Wernicke’s Encephalopathy (WE)
Risk factors for progression to severe withdrawal: High alcohol intake (>20 units/day), history
of severe withdrawal/DTs or withdrawal seizures, fever or sweating, tachycardia, respiratory
alkalosis, hypokalaemia, other psychiatric disorders, high levels of anxiety / confusion,
hypoglycaemia, insomnia,? Wernicke’s encephalopathy, multiple substance addiction/
deliberate self-poisoning or significant physical co-morbidity.
Risk factors for Wernicke’s encephalopathy: Intercurrent illness, DTs/treatment for DTs,
alcohol related seizures/treatment for alcohol related seizures, IV glucose administration,
significant weight loss, poor diet, signs of malnutrition, recent diarrhoea, recent vomiting,
drinking > 20 units daily, peripheral neuropathy.
Prophylactic IV Thiamine (Pabrinex®)
Dose
Frequency
Route
IV infusion over
30mins in 100mls
of sodium chloride
0.9%
Followed by oral thiamine 100mg three times daily indefinitely
1 x pair (amps 1 & 2)
Daily
Duration
3 days or until eating
and drinking
Oral thiamine should be prescribed for all patients once IV therapy is complete.
Commence Thiamine 100mg three times daily indefinitely.
11
9. Monitoring requirements:
Always ensure patients are nursed in a well-lit, cool environment with good ventilation.
Frequency of monitoring will depend on the patient’s CIWA-Ar score as outlined below:
CIWA-Ar Score
<10
Monitor CIWA-Ar and EWS score
Every 4 hours for 72 hours
10 – 15
Hourly and 1 hour post each dose for 8 hours, if stable every 2 hours for
8 hours, then if stable every 4 hours
> 15
Hourly and 1 hour post each dose for 8 hours, if stable every 2 hours for
8 hours, then if stable every 4 hours
Please note: CIWA-Ar assessment can be completed at any point, where felt appropriate
Monitoring should continue for the period of stabilisation.
If the patient is asleep, make a note on the CIWA-Ar scale with the date and time that the
patient is asleep. Once the patient wakens, recheck CIWA-Ar score and continue with
recommended frequency of monitoring.
`
10. Interpreting changes in the CIWA-Ar score:
Action
CIWA-Ar Score
Unchanged or decreases
Increases
Continue with the daily prescribed dose and recommended frequency of
monitoring. Commence fixed reducing dose the following day.
Administer additional PRN doses. Up to 3 additional PRN doses (or to a
max 250mg) can be given in 24hrs – if further doses are required - seek
medical review and consider increasing regular dose or switching PRN
benzodiazepine choice to lorazepam or diazepam
(appendix 8: Equivalence Table).
12
11. Managing breakthrough symptoms:
The recommended PRN doses must be prescribed for all patients.
Smaller and more frequent doses avoid excessive sedation and serve to reassure the anxious
patient. Administering of frequent smaller PRN doses in the event of AWS symptom
breakthrough is likely to be more effective than high regularly prescribed doses under most
circumstances. The exception to this is when prior clinical knowledge of the patient predicts
the need for higher regular doses from the start and is at the discretion of the individual senior
doctor/consultant. Examples of higher regular doses are 50-60mg qds for the first 24-48hrs.
There is no clear maximum licensed dose of chlordiazepoxide. Maximum dose is determined
rather by clinical response and the likelihood of accumulation.
Up to a maximum of 400mg in 24hrs has been used in very severe cases. Doses over the
recommended maximum of 250mg in 24 hours (Maudsley, March 2007 edition) must only be
used under the advice of a senior doctor/consultant. Saturation of benzodiazepine receptors is
a plausible explanation for limited benefit from dose escalation above usual levels and
sedation using neuroleptic and anaesthetic agents may be required.
Any increase in the CIWA-Ar score should prompt the additional administration of PRN doses,
up to a maximum of 3 doses (or to a max 250mg) in 24hrs. Where maximum PRN doses have
been required consider:
o increasing the regularly prescribed dose.
o switching the choice of PRN benzodiazepine e.g. from PRN chlordiazepoxide to PRN
lorazepam or diazepam in addition to the regularly prescribed chlordiazepoxide dose
(appendix 8: Equivalence Table).
After the stabilisation period (up to the first 3 days), benzodiazepines should not need to be
prescribed on a routine PRN basis. Patients exhibiting significant further symptoms may
have other complications and should be discussed with a senior doctor/consultant.
All too often patients receive PRN doses long after physical withdrawal has ended – serving as
an anxiolytic rather than withdrawal management. This should be avoided.
12. Severe/uncontrolled withdrawal symptoms:
(This section may be revised to be in accordance with any newly developed WHSCT Rapid
Tranquillisation Policy. Any advice here will be superseded by such a policy).
Consider increasing the frequency and dose of chlordiazepoxide up to 40mg hourly up to a
maximum of 3 doses. When increasing chlordiazepoxide doses or giving PRN doses, use
caution as over-intoxication may cause a paradoxical agitation. Refer to breakthrough
symptoms for guidance on giving PRN doses.
Night time brings on more severe symptoms in many patients, increasing the nocte dose of
chlordiazepoxide is considered first line treatment for night sedation; otherwise temazepam
10mg nocte ‘For hospital use only’ can be added.
For acute disturbances, consider giving:
o Lorazepam 2 to 4mg
o oral or IM route. Always consider oral before the IM route. Absorption from the injection
site is considerably slower if the intramuscular route is used and as rapid an effect may
be obtained by oral administration.
o the IM route should not be used in patients with bleeding/clotting disorders
o repeat up to 2 doses at 15 minute intervals
Please note Lorazepam Injection is contraindicated in severe liver impairment
13
For troublesome hallucinations or refractory to the above benzodiazepine loading
schedule, consider giving:
o PO/IM haloperidol in addition to the regularly prescribed benzodiazepine.
o use haloperidol with caution and for a short–term because of its epileptogenic potential.
o the patient’s diagnosis needs to be reviewed to consider the presence of any psychotic
illness or other organic pathology
Adult Haloperidol Dose
Route
Dose
Frequency
Max/24hrs
Oral
500micrograms
to 5mg
2 to 3 times daily
15mg
2.5 to 10mg
4 to 8 hrs
18mg
Route
Dose
Frequency
Max/24hrs
Oral
500micrograms
2 to 3 times daily
2mg
IM
(Elderly: half adult oral/IM dose)
Significant Liver impairment:
For patients refractory to the above sedation schedule:
o sedation using propofol or barbiturates by anaesthetic staff in HDU/ICU may be
necessary.
13. Seizures:
Alcohol related seizures occur usually within 12 hours after cessation and are rare beyond 48 hours.
Patient’s presenting with seizure should be admitted and observed for 24 hrs (EFNS Task Force
2005).
Adequate doses of chlordiazepoxide usually prevent withdrawal seizures.
For isolated seizures continue with standard regimen ensuring the patient has received an
adequate dose, increase dose if necessary.
If a patient develops prolonged or recurrent seizures give Lorazepam 2-4mg IV as a single
dose (in addition to existing benzodiazepine). Dilute 1:1 with Water for Injection before
administration. Lorazepam injection is stored in the fridge.
If seizing is prolonged (status epilepticus) seek senior medical advice.
14. Patient’s ‘Nil by mouth’:
IV or IM Diazepam is an alternative to chlordiazepoxide in patients unable to take oral
treatment. Absorption from the IM injection of diazepam may be variable, particularly for the
gluteal muscles. This route of administration should only be used if IV administration is not
possible.
IM route should not be used in patients with bleeding/clotting disorders
Facilities for resuscitation should always be available.
14
Give diazepam 10mg slow IV into a large vein over 2 minutes. Repeat after an interval of not
less than 4 hours if no improvement.
Please note Diazepam Injection is contraindicated in severe liver impairment
15. Discharge:
All patients should have been referred to the Addiction Liaison Services by this point.
Once patients have been seen by the Consultant and a treatment plan is in place, nurse led
discharge may proceed for patient’s on 30mg QID or less of chlordiazepoxide.
Medication on discharge for in-patient detox
All patients will be prescribed oral thiamine and the minimum amount of benzodiazepine to
complete the reducing course on discharge.
Shorter acting benzodiazepines (e.g. lorazepam) have a higher addictive potential and should
not be prescribed at discharge. Patients should be switched to low dose chlordiazepoxide to
complete the reducing course.
A maximum 5 days supply of chlordiazepoxide will be dispensed on discharge with the
following exceptions:
Maximum supply
Exceptions
•
•
history of overdose
previous history of benzodiazepine
dependence
1 day supply
(advise patient to attend GP as
soon as possible)
•
Expressed or strongly suspect intention to
sell dispensed medicine
Intention to continue drinking
No supply
(justification for this must be
clearly recorded in the medical
notes)
•
Medication on discharge for community/GP Detox
Discharge letter to be completed by doctor at ward level / A&E dept .*See Appendix 5
Patients will be supplied with one pharmacy pre-pack of 30 x 10mg chlordiazepoxide capsules
and advised to:
o Take 30mg qds for 1 day, 30mg tds for 1 day, 20mg tds for 1 day then as directed by
their GP
o Refer to the patient information leaflet provided to manage breakthrough symptoms
o Contact their GP within 3 days.
o Advised to complete course
15
16. Useful numbers:
Northern Sector
Self referral
AA
Tel:
028 9043 4848
Northlands Centre
Tel:
028 7131 3232
White Oaks
Tel:
00 353 7493 8440
Foyle Haven, 23a John St
Tel:
028 7136 5259
Damien House
12 Foyle Rd
L’Derry
BT 48 6SQ
Tel: 02871361156
Fax: 02871361157
Email: damienhouse@firsthousing@btinternet.com
Website: www.first-housing.com
Damien House is a 12 bedded hostel providing holistic support to men with mental health and alcohol misuse problems.
Access: NIHE referral and WHSCT referral
Opening hours 24/7
GP or social services referral
Woodlea House, Gransha Park Tel:
02871865237
Southern Sector
Self referral
AA
Tel:
028 9043 4848
Addiction Treatment Unit, Tyrone and Fermanagh Hospital,OMAGH
Tel: 028 82 83 5443/5365
Ramona House, 96 Circular Road, OMAGH, Co Tyrone BT79 7HA
Tel: 028 82252730
The Solace Project, The Rock 44 Mill Street, Irvinestown, BT94 1HP
Tel:
028 6862 8737
Fermanagh Community Addiction Team, Aisling Centre, 37 Darling Street, ENNISKILLEN
Tel: 028 66325811
GP or social services referral
nd
Western Drugs and Alcohol Co-Ordination Team, Anderson House, 2 Floor, Market Street, Omagh BT78 1EE
Tel:
028 8225 3950
Fax:
028 8225 3959
Community Drug Therapist, Addiction Treatment Unit, Tyrone and Fermanagh Hospital
OMAGH
Tel: 028 82 83 5203
Substitute Prescribing Nurse, Addiction Treatment Unit, Tyrone and Fermanagh Hospital
OMAGH
Tel: 028 82 83 5852
16
References
British National Formulary. BNF No 57. March 2009.
Department of Health. MOCAM – Model of Care for Alcohol Misusers. 2006
Electronic Medicines Compendium. October 2008. http://emc.medicines.org.uk/
EFNS Guideline on the diagnosis and management of alcohol-related seizures: report of an EFNS
task force. Brathen et al. European Journal of Neurology 2005, 12: 575-581
Link Pharmaceuticals. Trust Protocol: The management of the alcohol withdrawal syndrome and
Wernicke’s Encephalopathy. 2002
Mayo-Smith MF et al. Management of Alcohol Withdrawal Delirium. An evidence-based guideline.
Arch Intern Med 2004; 164: 1405-1412.
Morgan MY et al. Alcohol and Health. Medical Council on Alcoholism. London1998
Psychotropic Drug Directory: The professionals’ pocket handbook and aide memoire. Stephan
Bazire. 10th ed. United Kingdom: Fivepin Publishing Limited; 2003
Royal College of Physicians (RCP). Alcohol – can the NHS afford it? Royal College of Physicians of
London 2001
Scottish Intercollegiate Guidelines Network (SIGN) No 74. The Management of Harmful Drinking and
Alcohol Dependence in Primary Care, A National Clinical Guideline, September 2003 (Updated
2004).
Sullivan et al. Assessment of Alcohol Withdrawal: the revised clinical institute withdrawal assessment
for alcohol scale (CIWA-Ar). British Journal of Addiction 1989; 84: 1353
The Maudsley Prescribing Guidelines. 9th Edition. Maudsley Publications. March 2007
Thomson AD et al. Alcohol & Alcoholism 2002; 37 (6): 513-521.
World Health Organisation. International statistical classification of diseases and related health
problems. 10th ed. Geneva: The Organisation; 1992.
17
Evidence of severe AWS/DTs?
CIWA-Ar >15
N
Y
Admit to
AMU/ Erne
MSAU
Identify and treat any presenting physical injury first
Assess for patients requiring detoxification from alcohol
(+ve PAT score)
N
Serum ethanol +ve: Detox recommended when
serum ethanol <100mg/100ml and falling* and/or
if active withdrawal syndrome (refer to CIWA-Ar
score) and sedate earlier than this.
Psychosocial crisis
N
intervention
Y
Establish patient’s wishes re. future
alcohol consumption e.g. abstinence,
reduced or continued drinking
(involves motivational or brief intervention
process)
Refer to:
Social Services
Damien House
Ramona House
Primary Care Liaison
Alcohol Liaison Nurse / A&E Staff
AGREE GOAL WITH PATIENT
Reduction in alcohol intake
Abstinence**
Give encouragement
Advise reduction in alcohol intake
Advise to arrange appointment to
see GP within 3 days
Plan medically assisted detox
**absolute indications for abstinence
Alcohol-related organ damage
Severe dependence
Significant psychiatric disorders
**relative indications
Epilepsy
Social factors
Consider Community Detox or
Damien House
Or Ramona House
Discharge from A&E
Any contraindications to
Community Detox?
Give encouragement
Advise reduction in alcohol intake
Supply chlordiazepoxide and thiamine
pre-pack against a prescription
Advise to arrange appointment to see
GP within 3 days
Medical Consult
V Acutely confused or hallucinating
V H/O severe DTs or withdrawal
seizures
V ? Wernicke’s Encephalopathy
V Significant physical co-morbidity
V Severe vomiting and diarrhoea
V Multiple substance addiction/OD
V Electrolyte disturbances
N
Discharge to
Community Detox / GP
Y
Medical Detox.
Admit to AMU/Erne MSAU
Primary Care Liaison
V Suicide or self harm risk
V Acute psychotic illness
V Mental state assessment
required
* Falling serum ethanol implies two successive readings. Ideally detox should commence 6-8 hrs after last drink or when serum ethanol is zero or close to it.
I
PATIENT IDENTIFICATION STICKER:
PADDINGTON ALCOHOL TEST
PAT July 2005
Consider PAT for ALL the TOP 10 reasons for attendance . Circle number(s) – for any specific trigger(s);
1. FALL (i. trip)
2. COLLAPSE (i. fits)
3. HEAD INJURY (i. facial)
5. ACCIDENT (i.Burn, RTA)
6. UNWELL (i. Request detox / help, self neglect)
4. ASSAULT
7. NON-SPECIFIC G.I.
8. PSYCHIATRIC (specify)
9. CARDIAC (i. Chest pain) 10. REPEAT ATTENDER
Other (specify) :_________________________________________________________________________________________________________
Proceed only after dealing with patient’s ‘agenda,’ i.e. patient’s reason for attendance.
We routinely ask all patients with (state reason for screening) about their use of alcohol.
1
YES
NO (end)
Do you drink alcohol?
What is the most you will drink in any one day?
total per day (standard alcohol units)=
2
If necessary, please use the following guide to estimate total daily units.
(Standard pub measures in brackets; home measures often three times the amount!)
Beer / Lager
/ Cider
Strong Beer /
Lager / Cider
Wine
Fortified Wine
(Sherry , Martini)
Spirits
(Gin, Vodka, Whiskey)
Pints (2)
Pints (5)
Glasses (1.5)
Glasses (1)
Singles (1)
Cans / Small
Bottles (1.5)
Cans / Small
Bottles (4)
Bottles (9)
Large Bottles
(10)
Alcopop
Bottles (1.5)
Large Bottles
(4)
3
Bottles (12)
Bottles (30)
How often do you drink more than twice the recommended amount?
: Everyday
Dependent Drinker
(PAT+ve) (? Pabrinex )
: _____ times per week
Hazardous Drinker
(PAT+ve ?)
: Never / Less than weekly
GO TO QUESTION 4
YES (PAT+ve)
4
5
Do you feel your attendance here is related to alcohol?
NO
If PAT +ve give feedback eg “We advise you that this drinking is harming your health".
YES
NO - give leaflet
Would you like to see our Alcohol Liaison Nurse?
If “YES” to #5 give AHW appointment card and make appointment in diary (@ 10am) DATE ………………
Please note if patient admitted to ward ……………………………………………………………..
SIGNATURE:
NAME STAMP:
II
DATE:
HOW TO USE ‘PAT’
The Paddington Alcohol Test (PAT) is a clinical and therapeutic tool for screening hospital patients for alcohol problems
such as hazardous drinking and dependency.
The PAT was specifically developed for use by clinicians in a busy Accident & Emergency department, employing the
admission to hospital as a “TEACHABLE MOMENT” (Williams S et al, Drug & Alcohol Dependence 2005).
PAT is non-judgemental, enabling patients to develop insight into their drinking, its cause and effect.
Using the PAT, plus referral for specialist alcohol assessment, results in lower alcohol consumption and reduces the
likelihood of re-attendance. (Crawford, Patton, Touquet et al, Lancet, 2004)
It takes only about 30 seconds to complete the PAT.
1.
Deal with the patient’s reason for attending and their presenting condition first, thereby gaining their confidence so
they are in a more receptive frame of mind.
2.
If patient has one of the TOP 10 conditions, listed overleaf at the top of PAT, or other indication of recent
consumption of alcohol, proceed with the PAT questions.
3.
Question 1: ‘We routinely ask all patients with (this condition) if they drink alcohol - do you drink?’ If No: PATve, discontinue (providing clinician agrees with the answer).
4.
If yes: go to Question 2: What is the most that patient will drink in one day.
For United Kingdom: 8gms absolute alcohol = 10ml alcohol = 1 unit
Standard Alcohol Units (SAU) = % ABV x volume (in litres)
where ‘% ABV’ is ‘% of alcohol by volume’ as indicated on bottle or can.
Please use the guide to help you (and the patient) calculate amounts - drinks vary so much that the use of standard
alcohol units is necessary for consistency. It may be less judgemental to focus solely on quantity rather than what
they drink.
5.
Having estimated the number of units consumed, if this is more than double the recommended daily limits, ie 8 units
(male), or 6 units (female), ask Question 3: how often do they drink more than 8 or 6 units? This helps differentiate
the dependent drinker, who will need more complex management, from the hazardous or “binge” drinker who will
benefit from advise and information about cutting down or controlled drinking. The earlier that binge drinking is
detected the more effective is the use of PAT. The acceptance of an appointment with an Alcohol Liaison Nurse
(AHW) demonstrates awareness of a problem and the desire for help, thereby showing some insight.
6.
If there is evidence of chronic alcohol misuse, poor diet and confusion /ataxia /ophthalmoplegia: then give
I.V.Pabrinex at the earliest opportunity (I&II (X2) in 100ml 0.9% saline infused over half an hour). (Thompson et
al., Alcohol & Alcoholism, 2002).
7.
Everyone who has said yes to Q.1 should be asked Question 4: ‘Do you feel your current attendance is related to
alcohol?’ If yes then you have started the process of brief intervention by the patient associating drinking with
resulting hospital attendance. If they deny any association, but in your clinical judgement have been drinking, you
might say: ‘would you be in hospital if you had NOT been drinking?’
8.
Question 5: If “YES” Leave PAT form in AHW referrals box, with diary. Offer the patient an appointment with
the Alcohol Liaison Nurse at 10am on the next morning when Alcohol Liaison session is scheduled. NB it is known
that the earlier that appointment is offered, the more likely the patient will be to attend – please encourage them to
take the next available appointment rather than defer it.
If “NO” give them the “Think About Drink” leaflet and even the AHW appointment card as patient may change
their mind and return. File PAT form in patient notes. Complete all sections of the PAT
9. Prepare GP letter (“for appointment” or “declined”) unless patient admitted to ward.
For further information about the Paddington Alcohol Test (PAT) contact:
Professor R. Touquet - robin.touquet@st-marys.nhs.uk or Adrian Brown RMN –
ade.brown@nhs.net
III
Appendix 3: AUDIT Tool
1. How often do you have a drink containing alcohol?
(0) Never (Skip to Questions 9-10)
(1) Monthly or less
(2) 2 to 4 times a month
(3) 2 to 3 times a week
(4) 4 or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are
drinking?
(0) 1 or 2
(1) 3 or 4
(2) 5 or 6
(3) 7, 8, or 9
(4) 10 or more
3. How often do you have six or more drinks on one occasion?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
4. How often during the last year have you found that you were not able to stop
drinking once you had started?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
5. How often during the last year have you failed to do what was normally expected
from you because of drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
6. How often during the last year have you been unable to remember what happened
the night before because you had been drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
IV
7. How often during the last year have you needed an alcoholic drink first thing in the
morning to get yourself going after a night of heavy drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
8. How often during the last year have you had a feeling of guilt or remorse after
drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
9. Have you or someone else been injured as a result of your drinking?
(0) No
(2) Yes, but not in the last year
(4) Yes, during the last year
10. Has a relative, friend, doctor, or another health professional expressed concern
about your drinking or suggested you cut down?
(0) No
(2) Yes, but not in the last year
(4) Yes, during the last year
Add up the points associated with your answers above.
A total score of 8 or more indicates harmful drinking behaviour.
V
Guidance Notes
Please refer to full treatment guidelines
Using the CIWA-Ar Scale.
Assess the patient and rate each of the 10 criteria overleaf.
Add the score for each criterion to give the total CIWA-Ar score for the patient. The scale takes less than 5 minutes
to complete. It is not always necessary to ask the patient all 10 questions as observations will often be sufficient to
rate symptoms. The maximum possible score is 67.
Nausea and Vomiting
Tremor
Anxiety
Agitation
Paroxysmal Sweats
Tactile Disturbances
Auditory Disturbances
Visual Disturbances
Headache
Orientation
Do you feel sick to your stomach? Have you vomited?
Arms extended and fingers spread apart or holding a cup.
Patient feels tremulous inside
Do you feel nervous?
Have you any itching, pins and needles sensations, any burning, numbness or do you feel bugs crawling
on or under your skin?”
“Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing
anything that is disturbing to you? Are you hearing things you know are not there?”
Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you seeing
something that is disturbing to you? Are you seeing things you know are not there?
Does your head feel different? Does it feel like there is a band around your head? Do not rate for
dizziness or light-headedness. Otherwise, rate severity.
What day is this? Where are you? Who am I?
Prescribe benzodiazepine and thiamine treatment as soon as possible after admission
Record the baseline CIWA-Ar and EWS score and prescribe the recommended regular and ‘prn’
treatment doses for stabilisation. Correct all electrolyte and fluid disturbances.
Prescribe the first dose as a stat and administer immediately.
SEVERITY OF WITHDRAWAL
MILD
MODERATE
SEVERE
CIWA-AR SCORE
<10
10-15
>15
CHLORDIAZEPOXIDE STABILISATION
DOSE
A&E / DAY 1
10MG TO 20MG
QDS
+ PRN
20 TO 30MG QDS
+ PRN
BREAKTHROUGH PRN
10MG 2HRLY
20-30MG 2HRLY
40MG STAT, REPEATED
EVERY HOUR UP TO THREE
DOSES OR UNTIL
CIWA-AR <10, THEN 40MG
QDS
30MG - 40MG HRLY
STABILISATION DOSE
DAY 2
10MG TDS
+ PRN
30MG TID
+ PRN
30MG TDS
40MG NOCTE
+ PRN
30MG 2 HRLY
10MG 2HRLY
30MG 2HRLY
BREAKTHROUGH PRN
MAX 250MG/24 HRS (400MG/24 HRS HAS BEEN USED IN SEVERE CASES)
DETOX REGIME
20MG BD+
DAY 3
10MG BD
20MG QID
30MG BD (PRESCRIBE LARGER DOSES
IN THE EVENING)
DAY 4
DAY 5
DAY 6
DAY 7
DAY 8
DAY 9
10MG NOCTE
VI
20MG TDS
10MG QDS
10MG BD
10MG NOCTE
20MG QDS
10MG BD+ 20MG BD
10MG QDS
10MG TDS
10MG BD
10MG NOCTE
Interpreting changes in the CIWA-Ar score
Action
CIWA-Ar Score
Unchanged or decreases
Increases
•
Continue with the daily prescribed dose and routine assessment every 4 hours.
Commence fixed reducing dose the following day.
Administer additional PRN doses. Up to 3 additional PRN doses (or to a max of
250mg) can be given in 24hrs – then seek medical review and consider
increasing regular dose or switching PRN benzodiazepine choice to lorazepam
or diazepam. (Refer to equivalence chart).
If the patient is asleep, make a note on the CIWA-Ar chart with the date and time that the patient is
asleep.
Once patient wakens, recheck CIWA-Ar score and continue with recommended frequency of monitoring
Caution: Hypotension, respiratory depression, ataxia and sedation are signs of excessive dosing. Nursing
staff should omit or delay the prescribed dose if the patient is thought to be over sedated (cannot be easily
roused). The dose and choice of benzodiazepine should be reviewed in the presence of any of these
symptoms.
VII
Alcohol Withdrawal Assessment Chart
(CIWA-Ar Scale)
Date
Time (24hr)
Assess and rate each of the following:
Refer overleaf for guidance to using the CIWA-Ar scale
Nausea/Vomiting (0-7)
0) None, 1) mild nausea with no vomiting, 4) intermittent nausea
with dry heaves, 7) constant nausea, frequent dry heaves and
vomiting
Tremors (0-7)
0) no tremor, 1) not visible, but can be felt finger tip to finger tip
2) mild, 4) moderate, with patient’s arms extended,
7) severe, even with arms not extended
Anxiety (0-7)
0) no anxiety, at ease, 1) mildly anxious, 4)moderately anxious,
or guarded, so anxiety is inferred, 7) acute panic states as seen
in severe delirium or acute schizophrenic reactions
Agitation (0-7)
0) normal activity, 1)somewhat more than normal activity,
4) moderately fidgety and restless, 7) paces back and forth or
constantly thrashes about
Paroxysmal Sweats (0-7)
0) no sweat visible, 1)barely perceptible sweating, palms moist,
4) beads of sweat obvious on forehead, 7) drenching sweats
Tactile disturbances (0-7)
0) none, 1) very mild itching, pins & needles, burning /numbness,
2) mild itching, pins and needles, burning or numbness,
3) moderate, 4) moderately severe hallucinations
5) severe hallucinations, 6) extreme severely hallucinations
7) continuous hallucinations
Auditory Disturbances (0-7)
0) not present, 1) very mild harshness or ability to frighten
2) mild harshness or ability to frighten, 3) moderate
4) moderately severe hallucinations, 5) severe hallucinations
6) extremely severe hallucinations, 7) continuous hallucination
Visual Disturbances (0-7)
0) not present, 1) very mild sensitivity, 2) mild sensitivity,
3) moderate 4) moderately severe hallucinations 5) severe
hallucinations 6) extremely severe hallucinations 7) continuous
hallucinations
Headache (0-7)
0) not present, 1) very mild, 2) mild, 3) moderate, 4) moderately
severe, 5) severe, 6) very severe, 7) extremely severe
Orientation (0-4)
0) orientated and can do serial additions
1) cannot do serial additions or is uncertain about dates
2) disorientated for date by no more than 2 calendar days
3) disorientated for date by more than 2 calendar days
4) disorientated for place/or person
Total CIWA-Ar score
Dose given
PRN medicine
administration
Route
Time
Repeated CIWA-Ar score:
(1 hour after administration of PRN
dose)
Initials
CIWA-Ar
Score
Monitor CIWA-Ar & EWS
<10
Every 4 hours for 72 hours
10-15
Hourly and 1 hour post each dose
for 8 hours, if stable every 2 hours
for 8 hours, then if stable every 4
hours
As for 10-15
>15
Attach patient details / addressograph
VIII
ALWAYS ENSURE PATIENTS ARE NURSED IN A WELL-LIT, COOL
ENVIRONMENT WITH GOOD VENTILATION
Appendix 5: Example reducing chlordiazepoxide regimen
SEVERITY OF
WITHDRAWAL
MILD
MODERATE
SEVERE
CIWA-AR SCORE
<10
10-15
>15
CHLORDIAZEPOXIDE
STABILISATION DOSE
A&E / DAY 1
10MG TO
20MG QDS
+ PRN
20 TO 30MG
QDS
+ PRN
BREAKTHROUGH PRN
10MG 2HRLY
20-30MG
2HRLY
40MG STAT,
REPEATED EVERY
HOUR UP TO
THREE DOSES OR
UNTIL
CIWA-AR <10,
THEN 40MG QDS
30MG - 40MG HRLY
STABILISATION DOSE
DAY 2
10MG TDS
+ PRN
30MG TID
+ PRN
30MG TDS
40MG NOCTE
+ PRN
BREAKTHROUGH PRN
10MG 2HRLY
30MG 2HRLY
30MG 2 HRLY
MAX 250MG/ 24 HRS (400MG/24 HRS HAS BEEN USED IN SEVERE CASES)
DETOX REGIME
20MG BD+
DAY 3
10MG BD
20MG QID
30MG BD
(PRESCRIBE
LARGER DOSES IN
THE EVENING)
DAY 4
10MG NOCTE
20MG TDS
20MG QDS
DAY 5
10MG QDS
10MG BD+ 20MG
BD
DAY 6
10MG BD
10MG QDS
DAY 7
10MG NOCTE
10MG TDS
DAY 8
10MG BD
DAY 9
10MG NOCTE
IX
Appendix 6: Treatment Algorithm for Alcohol Withdrawal Syndrome
Assess the severity of withdrawal symptoms using the CIWA-Ar Scale
MILD
MODERATE / SEVERE
CIWA-Ar <10
CIWA-Ar >15
Are there risk factors for progression?
(Any one of the following significant active
comorbidities:
High alcohol intake (>20 units/day)
History of severe withdrawal/DTs or
withdrawal seizures
Fever, profuse sweating,
tachycardia, respiratory alkalosis
Hypokalaemia (<2.5mmol/L)
Other psychiatric disorders
High levels of anxiety / confusion
Hypoglycaemia
suspected Wernicke’s
encephalopathy
Multiple substance addiction/OD
Significant physical co-morbidity
No
Observe for:
Characteristic symptoms DT’s
Auditory or visual hallucinations
Clouding of consciousness
Confusion and disorientation
Delusions
Severe tremor
Paranoid ideas
Agitation
Fever with or without infection
Plus symptoms of autonomic overactivity
Impaired attention
Tachycardia
Systolic hypertension
Tachypnoea
Marked anxiety
Insomnia
Profound sweating (1 – 3 L in 24hr)
Yes
Medical detox NOT required,
refer community detox via
GP/psychiatric detox facility if
available
Consider
medical
admission &
treat
No
Significant liver impairment suspected?
No
Oral chlordiazepoxide
dose
IV Thiamine Pabrinex
then switch to oral
ReducedYes
oral
chlordiazepoxide dose or
oral lorazepam
1 x pair (amps 1&2) daily for 3 days
X
Yes
Obtain Medical advice
& consider Wernicke’s
Encephalopathy
Appendix 7: Treatment Algorithm for Wernicke’s Encephalopathy
Known/suspected alcohol misuser
PAT or AUDIT +VE, ETC.
YES
Presenting Symptoms
Any one or more from:
• Acute Confusion
• Decreased consciousness level including unconsciousness / coma
• Memory disturbance
• Ataxia / unsteadiness
• Ophthalmoplegia
• Nystagmus
NO
Consider Risk factors for Wernicke’s encephalopathy
•
•
•
•
•
•
•
•
•
•
Intercurrent ilness
DT’s / treatment for DT’s
Alcohol related seizures / treatment for alcohol related seizures
IV glucose administration
Significant weight loss
Poor diet
Signs of malnutrition
Recent diarrhoea
Recent vomiting
Drinking 20 units daily
No
Yes
Yes
Wernicke’s
Ascertain working
diagnosis and treat as
appropriate
Encephalopathy
IV Thiamine Pabrinex®
2 x pairs (amps 1& 2) three times daily
for 3 days
then 1 x pair (amps 1&2) daily for 3 to
5 days or until clinical improvement
IV Thiamine Pabrinex®
1 x pair (amps 1& 2) daily for 3 days
XI
Appendix 8: Benzodiazepine Equivalence Table
Equivalence Table (BNF 57, March 2009)
Benzodiazepine
Dose equivalent to chlordiazepoxide 15mg
Lorazepam
500micrograms
Diazepam
5mg
Nitrazepam
5mg
Temazepam
10mg
Commence oral Thiamine 100mg three times daily thereafter
Infuse over 30 minutes in 100ml of sodium chloride 0.9%
Facilities for treating anaphylaxis should be available when administered
XII
Patient Group Direction (PGD) for
Nurses/Pharmacists
PGD reference:
The administration of
Chlordiazepoxide
YOU MUST BE AUTHORISED BY NAME, UNDER THE CURRENT VERSION OF
THIS PGD BEFORE YOU UNDERTAKE WORK ACCORDING TO IT.
Date from which PGD operational:
Review date:
Expiry date:
1. CLINICAL CONDITION:
1.1 Indication
1.2 Inclusion criteria
www.emc.medicines.org.uk
www.bnf.org.uk
1.3.1 Exclusion criteria
(ABSOLUTE
contraindications Refer to Doctor)
1.3.2 Exclusion criteria
(RELATIVE
contraindications - where
advice should be sought
from a Doctor)
For the management of breakthrough symptoms of acute alcohol
withdrawal
•
Adult patients (>18 years old)
•
Patients assessed using the CIWA-Ar scale as requiring
benzodiazepine for symptomatic relief of withdrawal symptoms
•
Patients with monitored increases in their CIWA-Ar score
requiring further benzodiazepine
•
Patients under 18 years old
•
Known allergy or hypersensitivity to chlordiazepoxide or any
excipients contained within the product
•
Pregnancy and Breastfeeding
•
Acute pulmonary insufficiency
•
Respiratory depression
•
Phobic or obsessional states
•
Chronic psychosis
•
Chronic pulmonary insufficiency
•
•
•
•
•
1.3.3 Action if patient
excluded
16/07/2009
01/12/2010
01/12/2011
•
Chronic renal disease
Previously diagnosed chronic liver disease.
Clinically evident liver disease (jaundice, ascites,
encephalopathy,
spider
naevi,
palmar
erythema,
hepatomegaly, clinical stigmata of cirrhosis)
L Serum bilirubin, M albumin, L prothrombin time
Elderly (> 75 years old)
Patients excluded from this PGD will be referred to a Doctor.
If any further information is needed, or there is any doubt as to
the appropriateness of this PGD, Doctors can be consulted
within Altnagelvin, Tyrone County or Erne Hospitals, WHSCT.
XIII
1.3.4 Action if patient
declines
2. MEDICINE DETAILS:
2.1 Name, strength and
form of medicine
2.2 Route/Method of
administration
2.3 Dosage
(Include maximum dose if
appropriate)
2.4 Frequency
2.5 Duration of treatment
2.6 Maximum or minimum
treatment period
2.7 Quantity to
supply/administer
•
Patients declining treatment will be referred to a Doctor within
WHSCT. Document any patient refusal, and the action taken in
the patient’s records.
Chlordiazepoxide 10mg capsules
Oral
CIWA-Ar score
< 10:
10mg
10-15:
20-30mg
> 15:
30mg-40mg
Maximum single dose 40mg
2 hourly
Max up to 3 doses or 250mg/24 hrs
Max up to 3 doses or 250mg/24 hrs
The nurse/pharmacist using this PGD will obtain informed
patient/carer consent for the administration of chlordiazepoxide
Administration
As above
NOT for SUPPLY
No
2.8
Black Triangle
Drug?
2.9 Legal category
2.10 Use outside terms of
SPC?
2.11 Storage
2.12 Side effects
2.13 Concurrent
medication
POM
No
•
•
Store below 30°C
Store in the original container in a designated locked drug
cupboard. Access by authorised nursing and pharmacy staff
only.
•
Common adverse effects include drowsiness, sedation,
hypotension, unsteadiness and ataxia. The elderly are
particularly sensitive and may experience confusion.
•
•
Please refer to current BNF or SPC for full details
Please report any suspected adverse drug reactions to the
CSM/MHRA via the yellow card scheme (yellow cards are
available at the back of the BNF), or electronically via
www.yellowcard.mhra.gov.uk
•
Combined with centrally-acting drugs
such as neuroleptics, tranquilisers, antidepressants, hypnotics,
XIV
analgesics and anaesthetics, the sedative effects are likely to be
intensified. The elderly require special supervision.
•
Known inhibitors of hepatic enzymes, eg
cimetidine, have been shown to reduce the clearance of
benzodiazepines and may potentiate their action and known
inducers of hepatic enzymes, eg rifampicin, may increase the
clearance of benzodiazepines.
•
2.14 Advice to patient or
carer
2.15 Monitoring (if
applicable)
2.16 Follow-up
•
Refer to current BNF / SPC for full details.
Explain treatment purpose and course of action
Monitor CIWA-Ar and EWS score as outlined below
<10:
Every 4 hours for 72 hours
10-15:
Hourly and 1 hour post each dose for 8 hours, if stable every
>15:
Hourly and 1 hour post each dose for 8 hours, if stable every
•
CIWA-Ar assessment can be completed at any point, where
felt appropriate
•
If the patient is asleep, make a note on the CIWA-Ar scale
with the date and time that the patient is asleep. Once the patient
wakens, recheck CIWA-Ar score and continue with
recommended frequency of monitoring.
•
Hypotension, respiratory depression and sedation are signs of
excessive dosing. Nursing staff should omit or delay the
prescribed dose if the patient is thought to be over sedated and
cannot be easily roused. The dose and choice of benzodiazepine
should be reviewed in the presence of any of these symptoms.
•
Refer to Doctor within WHSCT to commence or review regular
benzodiazepine prescription
3. STAFF CHARACTERISTICS:
3.1 Professional
•
Registered nurse with the Nursing and Midwifery Council
qualifications
(NMC) on part RN 1(adult)
•
Registered pharmacist with the Pharmaceutical Society of
Northern Ireland
3.2 Specialist
•
Experience working with patients with alcohol withdrawal
competencies or
within Altnagelvin, Tyrone County and Erne Hospitals, WHSCT
qualifications
as a nurse or pharmacist
3.3 Continuing education
and training
•
Has undertaken agreed training to carry out clinical
assessment of patient leading to diagnosis that requires
treatment according to the indications listed in this PGD.
•
Has undertaken agreed training by pharmacy for working
under PGDs for the supply and administration of medicines.
Nurses and pharmacists using the PGD should be aware of
any changes to the recommendations for the medicine listed.
It is the responsibility of the individual to keep up-to-date with
•
•
XV
continued professional development.
4. RECORDS/AUDIT TRAIL:
4.1 Audit
arrangements
4.2 Records/Audit
Trail
Audits will be carried out annually by professional lead and ward
pharmacist.
Documentation regarding the use of the PGD will be entered in the
patient’s notes/medical records. This record will contain:
•
Patient’s name, address, date of birth and consent given
•
Unique patient number and GP contact details (If registered)
•
Identified allergies and current medicines taken.
•
Diagnosis (any relevant inclusion/exclusion criteria).
•
Administration under PGD
•
Enter medicine name, dose, form and route of administration in
medicine administration section of A&E chart or once only
section of medicine kardex
•
Details of any adverse drug reaction and actions taken
•
Advice given to patients
•
Referral arrangements (including self care)
•
Staff Signature
5. REFERENCES:
•
SPC: www.emc.medicines.org.uk Chlordiazepoxide 10mg capsules, accessed May 2009
•
BNF 57: www.bnf.org.uk Chlordiazepoxide 10mg capsules, accessed, May 2009
•
WHSCT Management and Treatment Guidelines for Acute Alcohol Withdrawal. May 2009
XVI