Alcohol Withdrawal Syndrome in Neurocritical Care Unit: Nicotine Replacement Therapy and Thiamine Deficiency

Excerpt

We thank Dr. Braillon for his interest in our recently published manuscript “Alcohol Withdrawal Syndrome in Neurocritical Care Unit: Assessment and Treatment Challenges” in Neurocritical Care [1]. First, we would like to highlight that assessment of nicotine withdrawal is beyond the scope of our review paper. We agree with the author that people who drink alcohol often smoke and vice versa. In fact, several neurobiological mechanisms may explain the strong relationship between tobacco and alcohol use [2]. As suggested in the letter, active smokers admitted to ICUs manifest more agitation, self-removal of devices, and need for physical restraint, and receive higher doses of sedatives, neuroleptics, and analgesics [3]. It is therefore important to assess nicotine withdrawal in this population; though similar to alcohol withdrawal, assessment is often challenging in those with neurological injuries. General critical care literature has provided conflicting evidence for routine nicotine replacement in ICU patients [4, 5]. Overall, studies in neurocritical care patients including aneurysmal subarachnoid hemorrhage have suggested no direct vasoconstriction effects of nicotine in the cerebral vasculature, but nicotine may affect endothelial function and nitric oxide synthesis and protein kinase C activity, and therefore, a risk versus benefit assessment should be performed prior to routine nicotine supplementation in critically ill patients [6]. …