Alcohol Withdrawal Syndrome

A l c o h o l W i t h d r a w a l S y n d ro m e
Richard W. Carlson, MD, PhDa,b,c,*, Nivedita N. Kumar, Edna Wong-Mckinstry, MDe,f, Srikala Ayyagari, MDg, Nitin Puri, MDh, Frank K. Jacksona,k, Shivaramaiah Shashikumar, MDi,j
KEYWORDS  Alcohol withdrawal syndrome  Alcoholism  Intensive care  Alcohol-related disease KEY POINTS
 Alcohol abuse and the societal and economic costs of alcoholdependency are major problems in both the United States and throughout the world.  In susceptible patients, alcohol withdrawal syndrome (AWS) is often precipitated by other medical or surgical disorders, and AWS can adversely affect the course of these underlying conditions.  Although the mortality rate of AWS has decreased over the past few decades, significant risk for morbidity and death remainif conditions such as multiple trauma, severe sepsis, acute respiratory failure, and alcoholic liver disease complicate management.
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Alcohol abuse and the societal and economic costs of alcohol dependency are major problems in both the United States and throughout the world.1 More than 8 million Americans are dependent on alcohol; twice the number who abuse illicit drugs.2 Alcoholabuse is associated with 85,000 deaths in the United States annually as well as additional morbidity and mortality related to accidents, suicides, family abuse, and other problems. The combined costs of alcohol abuse in the United States reach
The authors have no disclosures. a Department of Medicine, Maricopa Medical Center, Phoenix, AZ 85008, USA; b Department of Internal Medicine, College ofMedicine, University of Arizona, Phoenix, AZ, USA; c Department of Internal Medicine, Mayo Clinic College of Medicine, Scottsdale, AZ, USA; d Department of Medicine, Legacy Salmon Creek Medical Center, Vancouver, WA, USA; e Department of Medicine, University of Arizona, Tucson, AZ, USA; f Internal Medicine Department, College of Medicine, University of Arizona, 1501 North Campbell Avenue, Room 6408,Tucson, AZ 85724-5040, USA; g Department of Hospital Medicine, University of California San Diego School of Medicine, 200 West Arbor Drive, #8485, San Diego, CA 92103, USA; h Department of Internal Medicine, Inova Fairfax Hospital, Virginia Commonwealth University, Falls Church, VA, USA; i Department of Medicine, St John’s Mercy Medical Center, St. Louis University, St Louis, MO, USA; j MercyCritical Care Training Program, Critical Care Medicine, Saint Louis University, 621 South New Ballas Road, Suite 4006, Tower B, St Louis, MO 63141, USA; k Midwestern University, Glendale, Arizona * Corresponding author. Department of Medicine, Maricopa Medical Center, 2nd Floor, 2601 Roosevelt, Phoenix, AZ 85008. E-mail address: richardw_carlson@dmgaz.org Crit Care Clin 28 (2012) 549–585http://dx.doi.org/10.1016/j.ccc.2012.07.004 criticalcare.theclinics.com 0749-0704/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.

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200 billion dollars each year.3–6 Up to 40% of all emergency department patients have alcohol in their system, 10% of whom have blood alcohol levels above legal limits.7 Once admitted, 8% of patients of general hospitals have been shownto exhibit signs and symptoms of the alcohol withdrawal syndrome (AWS), and the prevalence of these admissions to an intensive care unit (ICU) of inner-city public hospitals may exceed 20%.8–11 Alcohol abuse directly or indirectly leads to acute and chronic conditions that affect all organ systems, and alcohol-use disorders are particularly common in critically ill patients.10–15 In thesusceptible patient AWS is often precipitated by other medical or surgical disorders with adverse effects on the course of both comorbid conditions and AWS. This review of AWS focuses on the scope of the clinical problem, historical features, pathophysiology, clinical presentation, and approaches to therapy, with particular emphasis on severe AWS that requires ICU management.
SCOPE OF THE PROBLEM

All...