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Therapy of alcohol withdrawal syndrome in intensive care unit patients following trauma

Results of a prospective, randomized trial

Spies, Claudia D. MD; Dubisz, Norman RA; Neumann, Tim MD; Blum, Susanne MD; Muller, Christian PhD; Rommelspacher, Hans MD; Brummer, Glenda MD; Specht, Martin MD; Sanft, Carsten MD; Hannemann, Lutz MD; Striebel, H. Walter DEAA MD; Schaffartzik, Walter MD

Clinical Investigation

Objectives To assess the effect of three different alcohol withdrawal therapy regimens in traumatized chronic alcoholic patients with respect to the duration of mechanical ventilation and the frequency of pneumonia and cardiac disorders during their intensive care unit (ICU) stay.

Design A prospective, randomized, blinded, controlled clinical trial.

Setting A university hospital ICU.

Patients Multiple-injured alcohol-dependent patients (n equals 180) transferred to the ICU after admission to the emergency room and operative management. A total of 180 patients were included in the study; however, 21 patients were excluded from the study after assignment.

Interventions Patients who developed actual alcohol withdrawal syndrome were randomized to one of the following treatment regimens: flunitrazepam/clonidine (n equals 54); chlormethiazole/haloperidol (n equals 50); or flunitrazepam/haloperidol (n equals 55). The need for administration of medication was determined, using a validated measure of the severity of alcohol withdrawal (Revised Clinical Institute Withdrawal Assessment for Alcohol Scale).

Measurements and Main Results The duration of mechanical ventilation and major intercurrent complications, such as pneumonia, sepsis, cardiac disorders, bleeding disorders, and death, were documented. Patients did not differ significantly between groups regarding age, Revised Trauma and Injury Severity Score, and Acute Physiology and Chronic Health Evaluation II score on admission. In all except four patients in the flunitrazepam/clonidine group, who continued to hallucinate, the Revised Clinical Institute Withdrawal Assessment for Alcohol Scale decreased to less than 20 after initiation of therapy. ICU stay did not significantly differ between groups (p equals .1669). However, mechanical ventilation was significantly prolonged in the chlormethiazole/haloperidol group (p equals .0315) due to an increased frequency of pneumonia (p equals .0414). Cardiac complications were significantly (p equals .0047) increased in the flunitrazepam/clonidine group.

Conclusions There was some advantage in the flunitrazepam/clonidine regimen with respect to pneumonia and the necessity for mechanical ventilation. However, four (7%) patients had to be excluded from the study due to ongoing hallucinations during therapy. Also, cardiac complications were increased in this group. Thus, flunitrazepam/haloperidol should be preferred in patients with cardiac or pulmonary risk. Further studies are required to determine which therapy suits individual patients. A symptom-orientated patient approach rather than one standard therapy should be considered.

(Crit Care Med 1996; 24:414-422)

From the Department of Anesthesiology and Operative Intensive Care Medicine (Drs. Spies, Neumann, Brummer, Specht, Sanft, Hannemann, Striebel, and Schaffartzik, and Mr. Dubisz) and the Department of Neurology (Dr. Blum), Benjamin Franklin Medical Center; the Department of Clinical Chemistry and Biochemistry (Dr. Muller) and the Department of Neuropsychopharmacology (Dr. Rommelspacher), Rudolf Virchow Medical Center, Free University Berlin, Berlin, Germany.

Supported, in part, by grant DFG HE 916/7-2 from the German Research Society.

Address requests for reprints to: Claudia Spies, MD, Klinik fur Anaesthesiologie und Operative Intensivmedizin, Universitaetsklinikum Benjamin Franklin, Freie Universitaet Berlin, Hindenburgdamm 30, 12200 Berlin, Germany.

© Williams & Wilkins 1996. All Rights Reserved.
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