Goodson Carrie M, Clark Brendan J, Douglas Ivor S
University of Colorado School of Medicine, Denver, Colorado; Denver Health Medical Center, Department of Medicine, Denver, Colorado.
Alcohol Clin Exp Res. 2014 Oct;38(10):2664-77. doi: 10.1111/acer.12529.
Severity of alcohol withdrawal syndrome (AWS) is associated with hospital mortality and length of stay. However, as there is no consensus regarding how to predict the development of severe alcohol withdrawal syndrome (SAWS), we sought to determine independent predictors of SAWS.
We conducted a systematic review and meta-analysis of studies evaluating hospitalized patients with AWS versus SAWS-delirium tremens (DT) and/or seizures. Random-effects meta-analysis [PRISMA guidelines] was performed on common baseline variables and predictive effects for development of SAWS were calculated using RevMan v5.2. Funnel plots were constructed, and tests of heterogeneity were performed.
Of 226 studies screened, 17 met criteria and 15 were included in the meta-analysis. The primary findings were that an incident occurrence of DT or alcohol withdrawal seizures was significantly predicted by history of a similar event (OR 2.58 for DT vs. no-DT, 95% CI 1.41, 4.7; OR 2.8 for seizure vs. no-seizure, 95% CI 1.09, 7.19). Both a lower initial platelet count and serum potassium level were predictive of an incident occurrence of DT (platelet count mean difference [MD] -45.64/mm(3) vs. no-DT, 95% CI -75.95, -15.33; potassium level MD -0.26 mEq/l vs. no-DT, 95% CI -0.45, -0.08), seizures, and SAWS. Higher initial alanine aminotransferase was seen in patients with SAWS (MD 20.97 U/l vs. no-SAWS, 95% CI 0.89, 41.05). Higher initial serum gamma-glutamyl transpeptidase was seen in patients with incident alcohol withdrawal seizures (MD 202.56 U/l vs. no-seizure, 95% CI 3.62, 401.5). Significant heterogeneity was observed, and there was evidence of publication bias. Notably, neither gender nor comorbid liver disease was predictive.
The course of prior episodes of AWS is the most reliable predictor of subsequent episodes. Thrombocytopenia and hypokalemia also correlate with SAWS. We propose further research into drinking patterns, gender, and medical comorbidities.
酒精戒断综合征（AWS）的严重程度与医院死亡率和住院时间相关。然而，由于在如何预测严重酒精戒断综合征（SAWS）的发生方面尚未达成共识，我们试图确定SAWS的独立预测因素。
我们对评估AWS患者与SAWS（震颤谵妄[DT]和/或癫痫发作）患者的研究进行了系统评价和荟萃分析。对常见基线变量进行随机效应荟萃分析[PRISMA指南]，并使用RevMan v5.2计算SAWS发生的预测效应。构建漏斗图并进行异质性检验。
在筛选的226项研究中，17项符合标准，15项纳入荟萃分析。主要发现是，既往有类似事件史可显著预测DT或酒精戒断癫痫发作的发生（DT与无DT相比，OR为2.58，95%CI为1.41，4.7；癫痫发作与无癫痫发作相比，OR为2.8，95%CI为1.09，7.19）。较低的初始血小板计数和血清钾水平可预测DT（血小板计数平均差[MD]-45.64/mm³与无DT相比，95%CI为-75.95，-15.33；钾水平MD-0.26 mEq/l与无DT相比，95%CI为-0.45，-0.08）、癫痫发作和SAWS的发生。SAWS患者的初始丙氨酸转氨酶水平较高（MD为20.97 U/l与无SAWS相比，95%CI为0.89，41.05）。酒精戒断癫痫发作患者的初始血清γ-谷氨酰转肽酶水平较高（MD为202.56 U/l与无癫痫发作相比，95%CI为3.62，401.5）。观察到显著的异质性，并有发表偏倚的证据。值得注意的是，性别和合并肝病均无预测作用。
既往AWS发作的病程是后续发作最可靠的预测因素。血小板减少症和低钾血症也与SAWS相关。我们建议对饮酒模式、性别和合并症进行进一步研究。
