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Recognition, Assessment, and Pharmacotherapeutic Treatment of Alcohol Withdrawal Syndrome in the Intensive Care Unit

Foertsch, Madeline J., PharmD, BCPS, BCCCP; Winter, Jessica B., PharmD, BCPS, BCCCP; Rhoades, Abigail G., PharmD, BCCCP; Martin, Lukas T., PharmD, BCCCP; Droege, Christopher A., PharmD, BCCCP; Ernst, Neil E., PharmD

doi: 10.1097/CNQ.0000000000000233
Original Articles

Alcohol withdrawal syndrome (AWS) is a complex neurologic disorder that develops after an acute reduction in or cessation of chronic alcohol consumption that alters neurotransmitter conduction. The incidence of AWS in the intensive care unit varies, but has been associated with poor outcomes. This is primarily driven by downregulation of gamma-aminobutyric acid (GABA) leading to autonomic excitability and psychomotor agitation. No clinical assessment tools have been validated to assess for AWS in the intensive care unit, particularly for patients requiring mechanical ventilation. The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised, may be considered to gauge the extent of withdrawal, but is not particular with acute presentations in this population. Symptom-triggered use of GABA agonist such as benzodiazepines remains the mainstay of pharmacotherapeutic intervention. Nonbenzodiazepine GABA agonists such as barbiturates and propofol as well as non-GABA adjunctive agents such as dexmedetomidine, ketamine, and antipsychotic agents may help reduce the need for symptom-triggered benzodiazepine dosing, but lack robust data. Agent selection should be based on patient-specific factors such as renal and hepatic metabolism, duration of action, and clearance. Institution-specific protocols directing GABA-acting medications and adjunctive medications for excitatory, adrenergic, and delirium assessments could be considered to improve patient outcomes and caregiver satisfaction.

Department of Pharmacy Services, UC Health—University of Cincinnati Medical Center, Ohio (Drs Foertsch, Winter, Droege, and Ernst); University of Cincinnati James L. Winkle College of Pharmacy, Ohio (Drs Foertsch, Winter, Rhoades, Martin, Droege, and Ernst); Department of Pharmacy Services, The Christ Hospital Health Network, Cincinnati, Ohio (Dr Rhoades); and Department of Pharmacy Services, St Elizabeth Healthcare, Edgewood, Kentucky (Dr Martin).

Correspondence: Madeline J. Foertsch, PharmD, BCPS, BCCCP, UC Health—University of Cincinnati Medical Center, 234 Goodman St, ML 0740, Cincinnati, OH 45219 (

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

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