Woods Anne Dabrow, Giometti Renee, Weeks Susan M
1 Penn Medicine Chester County Hospital, West Chester, Pennsylvania, USA2 Texas Christian University Center for Evidence Based Practice and Research: a Collaborating Center of the Joanna Briggs Institute, Fort Worth, Texas, USA.
JBI Database System Rev Implement Rep. 2015 Jan;13(1):224-52. doi: 10.11124/jbisrir-2015-1602.
Chronic alcohol consumption is a prevalent issue. Healthcare professionals often discover their patient has an alcohol consumption issue when they are admitted to the hospital and no longer have access to alcohol. The global standard for treating alcohol withdrawal syndrome (AWS) symptoms are benzodiazepines; however this therapy is often inadequate to control symptoms of delirium in adult intensive care unit (ICU) patients due to an imbalance of inhibitory and excitatory neurotransmitters.
The objective of the systematic review is to examine the clinical effectiveness of dexmedetomidine as an adjuvant to benzodiazepine-based therapy versus benzodiazepine-based therapy alone in decreasing the severity of delirium associated with AWS in adult ICU patients.
This review considered studies that included adult ICU patients over the age of 18 who were experiencing delirium associated with alcohol withdrawal. Patients admitted to the ICU with the diagnosis of AWS were included in the study.This review considered studies that evaluated dexmedetomidine as an adjuvant therapy to benzodiazepine-based therapy, compared to the use of benzodiazepine-based therapy alone in ICU patients experiencing alcohol withdrawal delirium.This review considered randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies, analytical cross sectional studies, case series, individual case reports and descriptive cross sectional studies for inclusion.The systematic review evaluated dexmedetomidine as an adjuvant to benzodiazepine-based therapy to decrease delirium severity in alcohol withdrawal in ICU patients. The general outcome of delirium severity was measured using the Clinical Institute Withdrawal Assessment Score - Revised (CIWA), the Ramsey scale, the Richmond Agitation Sedation Score (RASS) and the Confusion Assessment Method for the ICU (CAM-ICU).
The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in this review and included English language studies published after 1997. A search of Ovid/MEDLINE, EMBASE, Cochrane, Joanna Briggs Institute and nine other databases was conducted.
Two independent reviewers using the Joanna Briggs Institute's standardized appraisal tool critically appraised the studies. A third independent reviewer was available to appraise studies if the two original reviewers disagreed in their assessments. There were no disagreements in findings between the two independent reviewers.
Data was extracted using the standardized Joanna Briggs Institute's data extraction instruments.
Statistical pooling was done using meta-analysis and findings are presented using a forest plot and narrative form.
Four studies were included in the review, three retrospective case series and one prospective case series with a total sample size of 55 patients. Three studies used the CIWA score as the outcome measure and one study used the RASS score as the outcome measure. A meta-analysis of the three studies using the CIWA demonstrated that adjuvant use of dexmedetomidine with benzodiazepine-based therapy decreased CIWA scores (Weighted Mean Difference [WMD] -5.2, 95% Confidence Interval [CI] -6.24 to -4.16, p <0.0001). The final study using RASS scores reported improvement with adjuvant treatment with dexmedetomidine compared to benzodiazepine-based therapy alone.
The use of dexmedetomidine as an adjuvant to benzodiazepine-based therapy decreased delirium more effectively than benzodiazepine-based therapy alone in adult ICU patients experiencing alcohol withdrawal delirium as evidenced by a decrease in CIWA and RASS scores.
In adult ICU patients who are experiencing alcohol withdrawal delirium that is not controlled with benzodiazepine-based therapy alone, healthcare providers should consider dexmedetomidine as an adjuvant to standard benzodiazepine-based therapy.
The use of dexmedetomidine in the management of delirium associated with alcohol withdrawal in adult ICU patients should be further studied via large scale randomized controlled trials.
长期饮酒是一个普遍存在的问题。医疗保健专业人员经常在患者入院且无法再接触酒精时，才发现其存在饮酒问题。治疗酒精戒断综合征（AWS）症状的全球标准药物是苯二氮䓬类药物；然而，由于抑制性和兴奋性神经递质失衡，这种疗法往往不足以控制成人重症监护病房（ICU）患者的谵妄症状。
本系统评价的目的是研究右美托咪定作为基于苯二氮䓬类药物治疗的辅助药物与单纯基于苯二氮䓬类药物治疗相比，在降低成人ICU患者与AWS相关的谵妄严重程度方面的临床有效性。
本评价纳入的研究包括18岁以上患有与酒精戒断相关谵妄的成人ICU患者。诊断为AWS并入住ICU的患者纳入本研究。本评价纳入评估右美托咪定作为基于苯二氮䓬类药物治疗的辅助疗法的研究，与单纯使用基于苯二氮䓬类药物治疗的ICU酒精戒断谵妄患者进行比较。本评价纳入随机对照试验、非随机对照试验、准实验、前后对照研究、前瞻性和回顾性队列研究、病例对照研究、分析性横断面研究、病例系列、个案报告和描述性横断面研究。本系统评价评估右美托咪定作为基于苯二氮䓬类药物治疗的辅助药物，以降低ICU患者酒精戒断时的谵妄严重程度。谵妄严重程度的总体结果使用临床研究所戒断评估量表修订版（CIWA）、拉姆齐量表、里士满躁动镇静评分（RASS）和ICU谵妄评估方法（CAM-ICU）进行测量。
检索策略旨在查找已发表和未发表的研究。本评价采用三步检索策略，包括1997年后发表的英文研究。对Ovid/MEDLINE、EMBASE、Cochrane、乔安娜·布里格斯研究所和其他九个数据库进行了检索。
两名独立评审员使用乔安娜·布里格斯研究所的标准化评估工具对研究进行严格评估。如果两名原始评审员的评估意见不一致，可由第三名独立评审员评估研究。两名独立评审员在研究结果上没有分歧。
使用标准化的乔安娜·布里格斯研究所数据提取工具提取数据。
采用荟萃分析进行统计合并，并使用森林图和叙述形式呈现结果。
本评价纳入四项研究，三项回顾性病例系列和一项前瞻性病例系列，总样本量为55例患者。三项研究使用CIWA评分作为结局指标，一项研究使用RASS评分作为结局指标。对三项使用CIWA的研究进行的荟萃分析表明，右美托咪定与基于苯二氮䓬类药物的治疗联合使用可降低CIWA评分（加权平均差[WMD]-5.2，95%置信区间[CI]-6.24至-4.16，p<0.0001）。最后一项使用RASS评分的研究报告称，与单纯基于苯二氮䓬类药物的治疗相比，右美托咪定辅助治疗有改善。
在经历酒精戒断谵妄的成人ICU患者中，与单纯基于苯二氮䓬类药物的治疗相比，使用右美托咪定作为基于苯二氮䓬类药物治疗的辅助药物能更有效地降低谵妄程度，CIWA和RASS评分降低证明了这一点。
在单纯基于苯二氮䓬类药物治疗无法控制酒精戒断谵妄的成人ICU患者中，医疗保健提供者应考虑将右美托咪定作为标准基于苯二氮䓬类药物治疗的辅助药物。
应通过大规模随机对照试验进一步研究右美托咪定在成人ICU患者酒精戒断相关谵妄管理中的应用。
