(PO-157) (PO-157) Benzodiazepine Sparing Alcohol withdrawal protocol implementation in post-surgical head and neck cancer patients

Background:

Alcohol use disorder is seen in about one third of patients admitted to the intensive care unit and is associated with high rates of morbidity and mortality (3.) Patients with head and neck cancer have rates of comorbid alcohol use as high as 30-60%, which can complicate recovery (1). Traditionally, withdrawal is managed by assessing symptoms with the Clinical Institute Withdrawal Assessment (CIWA) and treating with as needed benzodiazepines or monitoring a benzodiazepine taper. Benzodiazepines perpetuate neurotransmitter dysregulation in alcohol withdrawal, but valproic acid can correct dysregulations of glutamic and GABAergic systems (2).

Methods:
We conducted an IRB approved retrospective chart review of patients admitted from January 2019 to February 2020 who had been admitted for head or neck cancer surgery and had concurrent diagnoses of alcohol use disorder. We juxtaposed this group to patients who underwent a standardized benzodiazepine sparing protocol from February 2020 to March 2021. We compared length of detoxification, benzodiazepine use, rates of delirium, length of stay, and CIWA scores.

Results:

In the initial population, 60% of patients underwent active alcohol withdrawal. Of these, 66.7% were given as needed benzodiazepines based on CIWA scores. 33.3% of patients in initial population received low doses of gabapentin. CIWA scores ranged from 2-8 in the initial group. Of the patients in the benzodiazepine sparing group 50% received valproic acid taper and 50% received Neurontin. Only one had an elevated CIWA score above 8, and only one patient had a onetime dose of lorazepam (for agitation).

Discussion:

This preliminary data demonstrates improvement in outcomes, increased control over withdrawal symptoms, reduced reliance of benzodiazepines, decreased CIWA scores, and minimization of episodes of agitation, and rates of delirium.

Conclusions:

In patients with significant medical comorbidities or post surgically, the utilization of a benzodiazepine sparing protocol is protective against alcohol withdrawal and possible autonomic instability, seizures or significant agitation (3). We have found significant benefit from proactive utilization of a benzodiazepine sparing protocol versus a traditional CIWA based reactive treatment model for alcohol withdrawal.

Citation

Genther, D. J., & Gourin, C. G. (2012). The effect of alcohol abuse and alcohol withdrawal on short‐term outcomes and cost of care after head and neck cancer surgery. The Laryngoscope, 122(8), 1739-1747.

Maldonado, J. R., Sher, Y., Ashouri, J. F., Hills-Evans, K., Swendsen, H., Lolak, S., & Miller, A. C. (2014). The “Prediction of Alcohol Withdrawal Severity Scale”(PAWSS): systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol, 48(4), 375-390.

Maldonado, J. R. (2017). Novel algorithms for the prophylaxis and management of alcohol withdrawal syndromes–beyond benzodiazepines. Critical care clinics, 33(3), 559-599.