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Alcohol, Nicotine, and Iatrogenic Withdrawals in the ICU

Awissi, Don-Kelena MSc Pharm, BCPS1; Lebrun, Genevieve MSc Pharm1; Fagnan, Mylene MSc Pharm1; Skrobik, Yoanna MD, FRCP2

doi: 10.1097/CCM.0b013e3182a16919
Creating and Implementing the 2013 ICU Pain, Agitation, and Delirium Guidelines for Adult Icu Patients

Objectives: The neurophysiology, risk factors, and screening tools associated with alcohol withdrawal syndrome in the ICU are reviewed. Alcohol withdrawal syndrome assessment and its treatment options are discussed. Description of nicotine withdrawal and related publications specific to the critically ill are also reviewed. A brief comment as to sedative and opiate withdrawal follows.

Data and Summary: The role of currently published alcohol withdrawal syndrome pharmacologic strategies (benzodiazepines, ethanol, clomethiazole, antipsychotics, barbiturates, propofol, and dexmedetomidine) is detailed. Studies on nicotine withdrawal management in the ICU focus mainly on the safety (mortality) of nicotine replacement therapy. Study characteristics and methodological limitations are presented.

Conclusion: We recommend a pharmacologic regimen titrated to withdrawal symptoms in ICU patients with alcohol withdrawal syndrome. Benzodiazepines are a reasonable option; phenobarbital appears to confer some advantages in combination with benzodiazepines. Propofol and dexmedetomidine have not been rigorously tested in comparative studies of drug withdrawal treatment; their use as additional or alternative strategies for managing withdrawal syndromes in ICU patients should therefore be individualized to each patient. Insufficient data preclude recommendations as to nicotine replacement therapy and management of iatrogenic drug withdrawal in ICU patients.

1Pharmacy Department, Hôpital Maisonneuve-Rosemont, Montréal, QC, Canada.

2Département de médicine, Université de Montréal, Montréal, QC, Canada.

The authors have disclosed that they do not have any potential conflicts of interest.

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© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins