Dexmedetomidine as an adjuvant in the treatment of alcohol withdrawal delirium: a case report

doi:10.1016/j.genhosppsych.2006.03.002

General Hospital Psychiatry

Volume 28, Issue 4, July–August 2006, Pages 362-363

https://doi.org/10.1016/j.genhosppsych.2006.03.002 Get rights and content

Abstract

In this case report, even a moderate dose of dexmedetomidine, a very selective α₂-adrenergic agent, resulted in a rapid response to alcohol withdrawal delirium after the standard treatment. Psychiatrists should be aware of this relatively new drug that provides advantages over clonidine, heavy sedation and secondary restraints. Dexmedetomidine should be further evaluated in the treatment of specific forms of aggressive behavior and complicated withdrawal states.

Introduction

Dexmedetomidine, a very selective α₂-adrenergic agonist, has sedative, analgesic, anxiolytic and sympatholytic effects mediated via central receptors, with a predictable hemodynamic profile and without inducing significant respiratory depression [1], [2]. The half-life of dexmedetomidine is only 2 to 3 h, shorter than that of clonidine, which makes it relatively easy and safe to titrate by continuous intravenous infusion. Dexmedetomidine alleviates the ethanol withdrawal symptoms in rats [3] and has shown some neuroprotective effects [4]. Dexmedetomidine has been used recently in cases of opioid and benzodiazepine withdrawal [5]. We report a clinical case of a complicated alcohol withdrawal delirium in which dexmedetomidine was used as an adjuvant.

Section snippets

Case report

A 50-year-old male was admitted to a referral center because of severe delirium and violent behavior. His past medical history was significant for severe alcohol dependence, without other drug abuse, and hypertension, which was medicated properly by candesartan 18 mg a day. He had been hospitalized over 10 times during the last 15 years in a psychiatric department for 3 to 5 days' periods because of alcohol-induced hallucinations and alcohol withdrawal delirium; the last of those had occurred

Discussion

In this case, even a low dose of dexmedetomidine added on the standard treatment resulted in a rapid and successful response to complicated alcohol withdrawal delirium. Previous case reports have concentrated more on opiate, benzodiazepine and polysubstance withdrawals [5], [6]. On the ground of this case, practice guidelines cannot be outlined, but the clinical experience opens prospects for the use of dexmedetomidine as an adjuvant in the treatment of complicated alcohol withdrawal delirium,

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Dexmedetomidine alleviates ethanol withdrawal symptoms in the rat
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Dexmedetomidine produces its neuroprotective effect via the α2A-adrenoceptor subtype
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Cited by (57)

Predictors of resistant alcohol withdrawal (RAW): A retrospective case-control study
2018, Drug and Alcohol Dependence
Benzodiazepine-resistant alcohol withdrawal (RAW), defined by a requirement of ≥ 40 mg of diazepam in 1 h, represents a severe form of withdrawal without predictive parameters. This study was designed to identify risk factors associated with RAW versus withdrawal without benzodiazepine resistance (nRAW).
A retrospective cohort of adults with severe alcohol withdrawal were screened. Demographic and clinical variables, collected through chart review, underwent logistic regression to select the subset that predicst RAW.
736 patients (515 nRAW, 221 RAW) were analyzed. RAW patients were younger (P < 0.001), male (P = 0.008) Caucasians (P = 0.037) with histories of psychiatric illness (P < 0.001), higher serum ethanol concentrations (P < 0.007), and abnormal liver enzymes (P = 0.01). RAW patients had significantly lower platelets (P < 0.001), chloride (P = 0.02), and potassium (P = 0.01) levels; severity of illness (SAPSII) (P < 0.001) and comorbidity scores (P < 0.001). Caucasian race and male gender were found to be 3.6 and 2.6 times more likely to be RAW. For every 1-unit increase in comorbidity and severity of illness scores, patients were 22% [OR(95% CI) 0.78 (0.66–0.90)] and 4% [0.96 (0.93–0.98)] less likely to be RAW. Patients with a psychiatric history or thrombocytopenia were 2 times more likely [2.02 (1.24–3.30); 2.13 (1.31–3.50), respectively] to be RAW.
These data demonstrate the predictive ability of a history of psychiatric illness, thrombocytopenia, gender, race, baseline severity of illness and comorbidity scores for developing RAW. Considering these characteristics in early withdrawal management may prevent progression to RAW outcomes.
Novel Algorithms for the Prophylaxis and Management of Alcohol Withdrawal Syndromes–Beyond Benzodiazepines
2017, Critical Care Clinics
Citation Excerpt :
No subject developed seizures or progressed to DTs. DEX is a selective AAG with sedative, analgesic, anxiolytic, and sympatholytic properties, generally devoid of significant respiratory depression.197 Its specificity for the alpha-2 receptor is 8 times that of CLO.198,199
Multicenter evaluation of pharmacologic management and outcomes associated with severe resistant alcohol withdrawal
2015, Journal of Critical Care
Citation Excerpt :
Resistant alcohol withdrawal is associated with a higher incidence of mechanical ventilation, a higher incidence of nosocomial pneumonia, and a longer intensive care unit (ICU) stay. Strategies studied to manage severe AWS include increasingly higher doses of BZDs, dexmedetomidine, phenobarbital, and propofol [9-20]. However, the preferred management of RAW remains unclear, as only phenobarbital has been evaluated [8].
A subset of patients with alcohol withdrawal syndrome does not respond to benzodiazepine treatment despite escalating doses. Resistant alcohol withdrawal (RAW) is associated with higher incidences of mechanical ventilation and nosocomial pneumonia and longer intensive care unit (ICU) stay. The objective of this study is to characterize pharmacologic management of RAW and outcomes.
Adult patients were identified retrospectively via International Classification of Diseases, Ninth Revision codes for severe alcohol withdrawal from 2009 to 2012 at 3 hospitals. Data collected included pharmacologic management and clinical outcomes.
A total of 184 patients met inclusion criteria. Sixteen medications and 74 combinations of medications were used for management. Propofol was the most common adjunct agent, with dexmedetomidine and antipsychotics also used. One hundred seventy-five patients (96.2%) were admitted to the ICU, with 149 patients (81.9%) requiring ventilator support. Median time to resolution of alcohol withdrawal syndrome from RAW designation was 6.0 days. Median ICU and hospital length of stay were 9.0 and 12.7 days, respectively.
Diverse patterns exist in the management of patients meeting RAW criteria, indicating lack of refined approach to treatment. High doses of sedatives used for these patients may result in a high level of care, illustrating a need for evidence-based clinical guidelines to optimize outcomes.
Influence of dexmedetomidine therapy on the management of severe alcohol withdrawal syndrome in critically ill patients
2014, Journal of Critical Care
Citation Excerpt :
The absence of a consistent definition for severe refractory AWS makes it difficult to evaluate candidacy for dexmedetomidine therapy. Current studies used heterogeneous definitions of severe AWS, which include ICU admission, degree of benzodiazepine use, hemodynamic instability, or alcohol withdrawal severity score [10–15]. The use of AWS scoring systems in the ICU is controversial given their dependence on patient participation.
Although benzodiazepines are first-line drugs for alcohol withdrawal syndrome (AWS), rapidly escalating doses may offer little additional benefit and increase complications. The purpose of this study was to evaluate dexmedetomidine's impact on benzodiazepine requirements and hemodynamics in AWS.
This retrospective case series evaluated 33 critically ill adults with a primary diagnosis of AWS from 2006 to 2012 at an academic medical center.
Dexmedetomidine began a median (interquartile range) of 11 (2, 32) hours into intensive care unit admission and was titrated to an infusion rate of 0.7 (0.4, 0.7) μg kg^− 1 h^− 1 to achieve the desired depth of sedation. In the 12 hours after dexmedetomidine began, patients experienced a 20-mg reduction in median cumulative benzodiazepine dose used (P < .001), a 14-mm Hg lower mean arterial pressure (P = .03), and a 17-beats/min reduction in median heart rate (P < .001). Four (12%) patients experienced hypotension (systolic blood pressure < 80 mm Hg) during therapy, and there were no cases of bradycardia (heart rate < 40 beats/min).
Dexmedetomidine decreased benzodiazepine requirements and improved the overall hemodynamic profile of patients with severe AWS. These results provide promising evidence about the potential benefit of dexmedetomidine for AWS.
Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients
2013, Medicina Intensiva
El óptimo manejo de la sedación, analgesia y delirium ofrece al paciente crítico comodidad y seguridad, facilita el buen desarrollo de medidas de soporte y manejo integral y disminuye complicaciones, impactando en un mejor desenlace.
Actualizar la Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo publicada en Medicina Intensiva en el 2007 y dar recomendaciones para el manejo de la sedación, analgesia y delirium.
Se reunió un grupo de 21 intensivistas procedentes de 9 países de la Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva, 3 de ellos además especialistas en epidemiología clínica y metodología para elaboración de guías. Se acogió la propuesta del Grading of Recommendations Assessment, Development and Evaluation Working Group para emitir el grado de recomendación y evaluar la calidad de la evidencia. La fuerza de las recomendaciones fue calificada como 1 = fuerte, o 2 = débil, y la calidad de la evidencia como A = alta, B = moderada, o C = baja. Expertos en búsqueda de literatura apoyaron con esta estrategia de búsqueda: MEDLINE a través de PUBMED, bases de datos de la biblioteca Cochrane a través de The Cochrane Library y la base de datos Literatura Latinoamericana y del Caribe en Ciencias de la Salud. Los miembros asignados a las 11 secciones de la guía, basándose en la revisión de la literatura, presentaron las recomendaciones, sustentadas y discutidas en sesiones plenarias, aprobando aquellas que superaron el 80% del consenso. La elaboración de las guías contó con el soporte de la Asociación Colombiana de Medicina Crítica y Cuidado Intensivo.
Para la elaboración de la guía fueron finalmente seleccionadas 467 referencias, observándose un importante aumento en el número y calidad de los estudios, permitiendo realizar 64 fuertes recomendaciones con evidencia alta y moderada, contrastando con las 28 de la edición anterior.
Esta guía contiene recomendaciones y sugerencias basadas en la mejor evidencia para el manejo de la sedación, analgesia y delirium del paciente crítico, incluyendo un paquete de medidas (bundle). Se destacan: evaluación del dolor y la agitación/sedación mediante escalas; usar inicialmente opioides para el control de la analgesia, adicionando técnicas multimodales para disminuir consumo de opioides; promover el menor nivel de sedación necesario, evitando la sobresedación; en caso de requerir medicamentos sedantes, escoger el más apropiado, evitando el uso rutinario de benzodiazepinas; por último, identificar factores de riesgo para delirium, prevenirlo, diagnosticarlo y manejarlo, con el medicamento más conveniente, ya sea haloperidol, antipsicóticos atípicos o dexmedetomidina, evitando el uso de benzodiazepinas y disminuyendo el uso de opioides.
Optimal management of sedation, analgesia and delirium offers comfort and security for the critical care patient, allows support measures to be applied more easily and enables an integral approach of medical care, at the same time that lowers the incidence of complications, wich translates in better patient outcomes.
To update the Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo published in Medicina Intensiva in 2007, and give recommendations for the management of sedation, analgesia, and delirium.
A group of 21 intensivists from 9 countries of the Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva, 3 of them also specialists in clinical epidemiology and methodology, gathered for the development of guidelines. Assessment of evidence quality and recommendations were made based on the Grading of Recommendations Assessment, Development and Evaluation system. Strength of recommendations was classified as 1 = strong, or 2 = weak, and quality of evidence as A = high, B = moderate, or C = low. Two authors searched the following databases: MEDLINE through PUBMED, The Cochrane Library and Literatura Latinoamericana y del Caribe en Ciencias de la Salud and retrieved pertinent information. Members assigned to the 11 sections of the guidelines, based on the literature review, formulated the recommendations, that were discussed in plenary sessions. Only those recommendations that achieved more than 80% of consensus were approved for the final document. The Colombian Association of Critical Medicine and Intensive Care (AMCI) supported the elaboration of this guidelines.
Four hundred sixty-seven articles were included for review. An increase in number and quality of publications was observed. This allowed to generate 64 strong recommendations with high and moderate quality of evidence in contrast to the 28 recommendations of the previous edition.
This Guidelines contains recommendations and suggestions based on the best evidence available for the management of sedation, analgesia and delirium of the critically ill patient, including a bundle of strategies that serves this purpose. We highlight the assessment of pain and agitation/sedation through validated scales, the use of opioids initially to apropiate analgesic control, associated with multimodal strategies in order to reduce opioide consumption; to promote the lowest level of sedation necessary avoiding over-sedation. Also, in case of the need of sedatives, choose the most appropiate for the patient needs, avoiding the use of benzodiazepines and identify risk factors for delirium, in order to prevent its occurrence, diagnose delirium and treat it with the most suitable pharmacological agent, whether it is haloperidol, atypical antipsychotics or dexmedetomidine, once again, avoiding the use of benzodiazepines and decreasing the use of opioids.
Adjunctive Dexmedetomidine in Alcohol Withdrawal Syndrome: A Systematic Review and Meta-analysis of Retrospective Cohort Studies and Randomized Controlled Trials
2023, Annals of Pharmacotherapy

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Case ReportDexmedetomidine as an adjuvant in the treatment of alcohol withdrawal delirium: a case report

Abstract

Introduction

Section snippets

Case report

Discussion

BaillieÁre's Clin Anaesthesiol

Alcohol

Eur J Pharmacology

Case Report
Dexmedetomidine as an adjuvant in the treatment of alcohol withdrawal delirium: a case report