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@[email protected] 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 - [email protected] or Adrian Brown RMN – [email protected] 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
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