Delirium Tremens (DTs)

Know the clock - Minor withdrawal symptoms begin around 6 hours after the last drink; alcohol hallucinosis follows around 12 hours and resolves in 24 to 48 hours; withdrawal seizures may appear up to 6 hours before hallucinosis. DTs typically begins at 48 hours and runs up to 5 days. A patient going to the OR on hospital day two or three sits squarely in that window. See the Alcohol Withdrawal Syndrome entry for the general syndrome and Substance Abuse - Alcohol for screening.

Score it with CIWA-Ar - The Clinical Institute Withdrawal Assessment for Alcohol, Revised is the best-validated severity tool. 8 or below is mild, 9 to 15 is moderate, and 15 or greater is severe with risk of seizures and DTs.

The presentation is an autonomic storm - Visual hallucinations, profound confusion, tachycardia, hypertension, hyperthermia, agitation, and diaphoresis. Intraoperatively that picture also fits light anesthesia, thyroid storm, sepsis, and malignant hyperthermia — work the differential before committing to a treatment.

Benzodiazepines are the treatment - Lorazepam, diazepam, or chlordiazepoxide, preferably IV. There is no consensus on dose and requirements vary drastically between patients, so titrate to effect. Symptom-triggered regimens, typically dosing at a CIWA score above 8, use less total drug over a shorter course than fixed-schedule regimens.

When benzodiazepines aren't enough - Phenobarbital added to a benzodiazepine is effective in severe DTs unresponsive to benzodiazepines alone. Propofol plus a benzodiazepine is an alternative but commits the patient to mechanical ventilation — plan the airway before you start.

Dexmedetomidine is an adjunct, not the primary drug - Central alpha-2 agonists including dexmedetomidine and clonidine should not be used alone as primary treatment. Dexmedetomidine works alongside a benzodiazepine at doses up to 0.7 mcg/kg/hr without requiring mechanical ventilation.

What isn't supported - Alcohol, antipsychotics, anticonvulsants, beta blockers, and baclofen are not recommended for treating alcohol withdrawal; there aren't enough studies supporting their safety in this setting.

Check the home list for bupropion - FDA labeling contraindicates bupropion in patients undergoing abrupt discontinuation of alcohol, benzodiazepines, barbiturates, or antiepileptic drugs. A patient admitted on bupropion who has just stopped drinking is exactly that situation.

Thiamine before glucose - Give multivitamins and thiamine before glucose to avoid precipitating Wernicke encephalopathy. Easy to invert when you're treating hypoglycemia in an agitated patient.

Anticipate the complications - DTs brings respiratory depression, seizures, arrhythmias, and aspiration pneumonitis. Even with appropriate therapy mortality is 5% to 15%, and it rises with pneumonia, pancreatitis, older age, and other medical comorbidity.

Postpone elective surgery - Failure to treat or a delay in diagnosis reliably produces high morbidity and mortality, and there is no anesthetic that treats it. The only thing that lowers mortality is aggressive resuscitation and treating concurrent illness, so get the patient through the episode before an elective case.

Ethanol is a CNS depressant; with prolonged use the brain adapts by inhibiting excitatory glutamate signaling and enhancing inhibitory GABA transmission. Withdraw the alcohol and that adaptation is unopposed, leaving the CNS excitatorily overloaded — the general picture covered under alcohol withdrawal syndrome.

Delirium tremens (DTs) is the severe end of that spectrum. More than half of people with a history of alcohol abuse show some withdrawal on stopping, but only 3% to 5% develop the profound confusion, autonomic hyperactivity, and cardiovascular collapse that define DTs; lifetime risk in the alcohol-abusing population is roughly 5% to 10%. Minor symptoms start about 6 hours after the last drink, but DTs itself appears as early as 48 hours after cessation and can last up to 5 days. Untreated mortality runs as high as 37%; with early recognition and treatment it falls below 5%.