Dyal Susanne, MacLaren Robert
University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, USA.
Hosp Pharm. 2019 Feb;54(1):22-31. doi: 10.1177/0018578718769241. Epub 2018 Apr 13.
Alcohol withdrawal occurs commonly but diagnosis and therapies have not been described. To characterize practices regarding the assessment and treatment of acute severe alcohol withdrawal and describe perceived barriers to therapies. A random sample of 500 US-based critical care pharmacists received the pretested, electronically distributed questionnaire. 94 (20%) of 471 eligible recipients responded with diverse representation. Manifestations of alcohol withdrawal that were commonly rated as severe were seizures (91.3%), not oriented to person/place/date (84.1%), delusions (73.8%), diastolic blood pressure >110 mmHg (51.7%), inconsolable agitation (50.7%), and tachycardia (50.7%). Scoring tools were considered highly effective for assessing severity by 43 respondents (45.8%). Management protocols existed in 86 (90.5%) institutions. Sixty-eight (72.3%) respondents indicated protocols were used often/routinely for initial management but only 23 (24.5%) for adjunctive therapies (p<0.0001). Agents employed for initial and adjunctive management were benzodiazepines (92.6% and 61.7%, respectively, p<0.0001), clonidine (29.8% and 34%, respectively), haloperidol (26.6% and 33%, respectively), and barbiturates (20.2% and 24.5%, respectively). Adjunctive agents were most commonly added to reduce dosages of benzodiazepines (antipsychotics, barbiturates, alpha-2 agonists), prevent respiratory depression (alpha-2 agonists), prevent or treat autonomic symptoms (alpha-2 agonists), and prevent or treat agitation/delusions (antipsychotics, barbiturates, alpha-2 agonists). Agents with common barriers to use were dexmedetomidine (bradycardia, hypotension, cost), propofol (hypotension, tracheal intubation required), and ketamine (lack of supportive data). Assessment and management strategies of acute severe alcohol withdrawal vary considerably. Benzodiazepines are the mainstay of treatment. Other agents are commonly used to prevent complications from benzodiazepines or treat agitation/delusions.
酒精戒断很常见，但诊断和治疗方法尚未得到描述。目的是描述急性严重酒精戒断的评估和治疗方法，并描述治疗中存在的障碍。对500名美国重症监护药师进行随机抽样，发放经过预测试的电子问卷。471名符合条件的受访者中有94名（20%）进行了回复，具有不同的代表性。通常被评为严重的酒精戒断表现包括癫痫发作（91.3%）、对人物/地点/日期无定向感（84.1%）、妄想（73.8%）、舒张压>110 mmHg（51.7%）、无法安抚的躁动（50.7%）和心动过速（50.7%）。43名受访者（45.8%）认为评分工具对评估严重程度非常有效。86家（90.5%）机构存在管理方案。68名（72.3%）受访者表示方案常用于/常规用于初始管理，但仅23名（24.5%）用于辅助治疗（p<0.0001）。用于初始和辅助管理的药物分别是苯二氮䓬类药物（分别为92.6%和61.7%，p<0.0001）、可乐定（分别为29.8%和34%）、氟哌啶醇（分别为26.6%和33%）和巴比妥类药物（分别为20.2%和24.5%）。添加辅助药物最常见的目的是减少苯二氮䓬类药物的剂量（抗精神病药物、巴比妥类药物、α-2激动剂）、预防呼吸抑制（α-2激动剂）、预防或治疗自主神经症状（α-2激动剂）以及预防或治疗躁动/妄想（抗精神病药物、巴比妥类药物、α-2激动剂）。使用存在常见障碍的药物包括右美托咪定（心动过缓、低血压、费用）、丙泊酚（低血压、需要气管插管）和氯胺酮（缺乏支持数据）。急性严重酒精戒断的评估和管理策略差异很大。苯二氮䓬类药物是治疗的主要药物。其他药物常用于预防苯二氮䓬类药物引起的并发症或治疗躁动/妄想。
