Roseman University of Health Sciences, College of Pharmacy, Henderson, NV, United States.
Cleveland Clinic, Cleveland, OH, United States.
Alcohol. 2020 Feb;82:23-27. doi: 10.1016/j.alcohol.2019.07.004. Epub 2019 Jul 18.
A symptom-triggered lorazepam regimen is the standard for treating alcohol withdrawal syndrome (AWS) in an inpatient setting. However, in severe AWS, lorazepam requirements can reach significant amounts and lead to risk of delirium and propylene glycol toxicity. Phenobarbital has been shown to be an effective adjunctive therapy for AWS, reducing benzodiazepine use, in the emergency department. The purpose of this study is to determine the efficacy and safety of phenobarbital in adjunct to symptom-triggered lorazepam for severe AWS vs. lorazepam alone in the intensive care unit (ICU). A retrospective cohort was conducted at Cleveland Clinic hospitals from 2013 to 2018 of ICU patients with AWS receiving either phenobarbital adjunct to symptom-triggered lorazepam or lorazepam alone. The primary outcome was the total duration of treatment. Secondary outcomes include ICU length of stay, change in CIWA-Ar score at 24 h, incidence of hypotension, mechanical ventilation, and serum osmolar gap. A total of 72 ICU patients were included with 36 patients in each arm. The median duration of treatment in the phenobarbital adjunct arm was 2.7 days (IQR = 1.7-6.4), compared to 3.1 days (IQR = 1.6-4.8) in the lorazepam arm (p = 0.578). The median ICU length of stay was similar between both arms [4.1 days (IQR = 2.4-8.4) vs. 4.5 days (IQR = 2.8-6.1), p = 0.727]. The average change in CIWA-Ar from baseline at 24 h was significantly lower for those who received phenobarbital (1.8 ± 9.0 vs. 6.5 ± 8.5, p = 0.028). Three patients in the phenobarbital-adjunct group received mechanical ventilation after starting phenobarbital treatment. There were no new incidences of hypotension or increased osmol gap >10 mmol/L after starting treatment in both groups. In conclusion, phenobarbital is an effective adjunct to symptom-triggered lorazepam in severe alcohol withdrawal in the ICU with no significant difference in adverse events.
症状触发的劳拉西泮疗法是治疗住院患者酒精戒断综合征（AWS）的标准方法。然而，在严重的 AWS 中，劳拉西泮的需求可能会达到很高的水平，并导致谵妄和丙二醇毒性的风险。苯巴比妥已被证明是 AWS 的一种有效辅助治疗方法，可减少急诊科中苯二氮䓬的使用。本研究的目的是确定苯巴比妥联合症状触发的劳拉西泮治疗重症 AWS 与单独使用劳拉西泮在重症监护病房（ICU）中的疗效和安全性。2013 年至 2018 年，克利夫兰诊所医院对接受苯巴比妥联合症状触发的劳拉西泮或单独使用劳拉西泮治疗的 AWS 患者进行了回顾性队列研究。主要结局是治疗的总持续时间。次要结局包括 ICU 住院时间、24 小时 CIWA-Ar 评分变化、低血压、机械通气和血清渗透压间隙的发生率。共纳入 72 例 ICU 患者，每组 36 例。苯巴比妥辅助治疗组的治疗中位时间为 2.7 天（IQR=1.7-6.4），而劳拉西泮组为 3.1 天（IQR=1.6-4.8）（p=0.578）。两组 ICU 住院时间相似[4.1 天（IQR=2.4-8.4）vs. 4.5 天（IQR=2.8-6.1），p=0.727]。24 小时时 CIWA-Ar 自基线的平均变化在接受苯巴比妥治疗的患者中明显较低（1.8±9.0 vs. 6.5±8.5，p=0.028）。苯巴比妥辅助治疗组中有 3 例患者在开始苯巴比妥治疗后接受了机械通气。两组在开始治疗后均无新的低血压或渗透压间隙增加>10mmol/L 的事件发生。总之，苯巴比妥是 ICU 中严重酒精戒断症状触发的劳拉西泮的有效辅助治疗方法，且不良反应无显著差异。
