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Challenges in Prediction, Diagnosis, and Treatment of Alcohol Withdrawal in Medically Ill Hospitalized PatientsA Teachable Moment

Educational Objective
To describe the natural history of alcohol withdrawal and the limitations and potential harms of Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocols.
1 Credit CME

An older man was admitted to the hospital for planned bowel resection. He reported drinking 8 to 10 ounces of whiskey daily for many years. During previous hospitalizations, he had no documented alcohol withdrawal symptoms or seizures. His last drink was 3 days prior to admission.

Over the first week postoperatively, he had no symptoms of alcohol withdrawal. On postadmission day 6 he developed an anastomotic leak, requiring urgent reoperation and antibiotics. On postadmission day 9, he became acutely disoriented and inattentive, with new abdominal tenderness. Imaging showed large intra-abdominal abscesses, and percutaneous drains were placed. His heart rate and blood pressure remained normal.

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Article Information

Corresponding Author: Thomas D. Brothers, MD, 483 Bethune Building, 1276 South Park St. Halifax, Nova Scotia B3H 1K5, Canada (thomas.brothers@dal.ca).

Published Online: April 27, 2020. doi:10.1001/jamainternmed.2020.1091

Conflict of Interest Disclosures: Dr Brothers is supported in part by the Ross Stewart Smith Memorial Fellowship in Medical Research from Dalhousie University Faculty of Medicine. Dr Bach reported grants from the Michael Smith Foundation for Health Research outside the submitted work. No other disclosures were reported.

Acknowledgments: We thank the patient for granting permission to publish this information.

References
1.
Maldonado  JR , Sher  Y , Das  S ,  et al.  Prospective validation study of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) in medically ill inpatients: a new scale for the prediction of complicated alcohol withdrawal syndrome.   Alcohol Alcohol. 2015;50(5):509-518. doi:10.1093/alcalc/agv043PubMedGoogle ScholarCrossref
2.
British Columbia Centre on Substance Use (BCCSU). B.C. Ministry of Health, B.C. Ministry of Mental Health and Addictions. Provincial Guideline for the Clinical Management of High-Risk Drinking and Alcohol Use Disorder. Vancouver, B.C.: BCCSU; 2019. https://www.bccsu.ca/clinical-care-guidance/. Accessed January 5, 2020.
3.
Eloma  AS , Tucciarone  JM , Hayes  EM , Bronson  BD .  Evaluation of the appropriate use of a CIWA-Ar alcohol withdrawal protocol in the general hospital setting.   Am J Drug Alcohol Abuse. 2018;44(4):418-425. doi:10.1080/00952990.2017.1362418PubMedGoogle ScholarCrossref
4.
Egholm  JW , Pedersen  B , Møller  AM , Adami  J , Juhl  CB , Tønnesen  H .  Perioperative alcohol cessation intervention for postoperative complications.   Cochrane Database Syst Rev. 2018;11(11):CD008343. doi:10.1002/14651858.CD008343.pub3PubMedGoogle Scholar
5.
Roy  PJ , Worsham  C .  Treating the “wake-up call” of alcohol use: a teachable moment.   JAMA Intern Med. 2017;177(12):1849-1850. doi:10.1001/jamainternmed.2017.5502PubMedGoogle ScholarCrossref
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