CLINICAL UPDATES

Alcohol use disorders (AUDs) are common among patients in the United States. Alcohol consumption is associated with increased trauma, and patients with AUDs are often admitted to surgical and trauma services. The incidence of AUDs is higher among patients in surgical settings than among patients in other hospital settings or the general population. In a study of 1,602 consecutive trauma patients,1 685 (43%) had a measurable blood alcohol level.

Chronic alcohol use contributes to the severity or incidence of cardiovascular, neurologic, gastrointestinal, neoplastic, and hematologic diseases. Many of these alcohol-associated diseases lead directly to the need for surgical intervention (eg, alcohol-associated trauma) and can increase operative risks (eg, alcohol-associated hypertension).

Identifying alcohol use problems in surgical patients in the perioperative period is a challenge for treating physicians, anesthesiologists, and surgeons. Once identified, AUDs can be effectively managed to improve operative outcomes. Furthermore, the perioperative period is an opportune time to motivate patients to change their drinking behaviors.

Defining the spectrum of AUDs is helpful in the perioperative management of affected patients. Two broad categories of AUDs may be encountered in the perioperative period: (1) at-risk drinking and (2) alcohol abuse and dependence (table 1). At-risk drinkers are persons who consume hazardous or harmful levels of alcohol but do not meet the criteria for alcohol abuse or dependence.2 At-risk drinking is often variably defined, but alcohol abuse and alcohol dependence are formally defined by criteria in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).2 Persons with alcohol abuse or dependence can have significant withdrawal complications in the perioperative period, including alcohol withdrawal syndrome (AWS).

Alcohol withdrawal syndrome

This clinical diagnosis consists of a constellation of signs and symptoms, including autonomic hyperactivity and impaired social and occupational functioning, that occur after a patient ceases or severely reduces alcohol consumption (table 2).2 Most patients who experience AWS have mild to moderate symptoms and do not need pharmacologic treatment.

Severe symptoms of AWS can peak within 4 days after onset and usually subside within a week. Seizures can occur with AWS. However, the most serious complication of AWS is delirium tremens, a life-threatening event. Delirium tremens can develop 3 to 5 days after the onset of withdrawal symptoms and is characterized by elevated temperature, tachycardia, hypertension, tremulousness, diaphoresis, hallucinations, disorientation, agitation, and urinary incontinence. Fortunately, delirium tremens is rare, occurring in less than 5% of dependent drinkers, and with proper treatment, the morbidity and mortality due to delirium tremens can be reduced.3

The incidence of AWS is two to five times higher in surgical and trauma patients than in all other hospitalized patients.4,5 Abstinence from drinking, as imposed by hospital admission, places patients with abuse or dependence at risk for AWS. Additionally, the stress of surgery predisposes patients to AWS or may exacerbate existing AWS.5 Because of the time course of AWS, symptoms may begin unexpectedly in the postoperative period and complicate surgical recovery. All patients with AUDs are at increased risk for perioperative complications, but the development of AWS in alcohol-dependent patients constitutes an independent cause of increased morbidity.5

Patients with AWS can be treated through a process known as medical detoxification. Detoxification concurrently treats AWS, promotes respite from alcohol consumption, and prevents subsequent adverse events. The primary goal of medical detoxification is to safely transition patients from detoxification to rehabilitation services.

Evidence from a large meta-analysis and a recent review of AWS treatment strategies supports the use of benzodiazepines as first-line detoxification treatment for AWS.6,7 Benzodiazepines are effective in treatment of AWS because they mimic the central nervous system effects of alcohol at the γ-aminobutyric acid (GABA) receptor, thereby suppressing the withdrawal response. Other medications can also be used to treat AWS; treatment options were recently reviewed by Mayo-Smith and associates.7

Some surgical units continue to use intravenous or oral alcohol for the prevention of AWS. A recent survey of US teaching hospitals found that more than 50% of responding institutions had used oral or intravenous ethanol to prevent or treat AWS.8 The use of ethanol replacement therapies for AWS remains controversial, and limited data are available to support this practice.7 Whereas several case series have examined this approach, intravenous or oral alcohol has not been shown to be superior to appropriate benzodiazepines in the treatment of AWS.

Preoperative assessment for AUDs

To manage AUDs in the perioperative period, it is essential to identify patients with AUDs efficiently and effectively, preferably prior to surgery. Use of short, validated screening instruments is the most effective way to screen for at-risk drinking and alcohol abuse and dependence.9 Screening strategies to detect the range of alcohol use disorders generally include a quantity and frequency screening test (eg, the Alcohol Use Disorders Identification Test) and a screen for alcohol abuse or dependence (eg, the CAGE Questionnaire). A past history of alcohol consumption, comorbid medical or psychiatric conditions, physical examination findings, and laboratory characteristics may assist in identifying AUDs. Among patients who are unable to communicate (because of trauma, for example), physical and laboratory characteristics may be the only objective measures to assess for AUD diagnoses.

Preoperative interventions for at-risk alcohol drinkers include encouragement of abstinence, brief interventions, and referral for substance abuse counseling. Alcohol-dependent patients at risk for AWS may undergo preoperative detoxification and rehabilitation, prophylaxis for AWS, referral to specialty addiction services, or all of these.

Preoperative treatment of AUDs

Abstinence prior to surgery likely offers the best method of reducing or eliminating perioperative complications due to AUDs. However, research supporting preoperative abstinence for prevention of perioperative complications is scarce. In one study,10 patients prior to colorectal surgery who were consuming more than 60 g of ethanol a day were randomly assigned to either 1 month of pharmacologic aversion therapy (controlled abstinence) or no intervention. Investigators found that the abstinence group experienced significantly fewer postoperative complications (myocardial ischemia, arrhythmias, infections, and hypoxemic episodes) than the control group. Abstinence recommendations are particularly useful for persons who are consuming at-risk levels of alcohol.

Preoperative detoxification of a patient with alcohol abuse or dependence may minimize the risk of surgery for patients with AUDs. Unfortunately, no studies have evaluated the effect of preoperative alcohol detoxification on surgical outcomes. However, preoperative detoxification may still prove to be useful in cases of elective surgery and for patients who are interested in reducing the length of their postoperative recovery.

Some patients may be unable to choose preoperative detoxification prior to surgery, because emergent surgery is needed or the patient is unable to communicate. For these patients, administration of prophylactic therapy (ie, scheduled doses of benzodiazepines throughout the perioperative period) can prevent the development of AWS. The therapy should be initiated upon cessation of alcohol consumption. Providing early and adequate prophylaxis for AWS can reduce postoperative complications and shorten the length of stay in the intensive care unit.11

The decision to consult an addiction specialist or psychiatrist experienced in evaluation and treatment of AUDs depends on the treating physician's level of comfort in dealing with AUDs. Involvement prior to surgery, if possible, is extremely important because this allows the consulting physician to interview the patient, identify the presence of AUD, determine risk of AWS, and develop a plan with the patient to minimize morbidity from surgery and AUD.

Management of AUDs in the immediate perioperative period

During surgery, patients with AUDs require special attention. Awareness of a patient's AUD allows for anticipation of increased anesthesia and analgesia requirements and a heightened response to surgical stress. Acute alcohol consumption prior to surgery may prolong the duration of action of several medications used during surgery, including propranolol and phenobarbital.12 Chronic alcohol consumption induces the cytochrome P-450 system, potentially shortening the duration of action of medications used during surgery.

Several studies have documented increased anesthesia requirements among patients with AUDs. A study of patients consuming more than 40 g of alcohol a day for at least 2 years concluded that the doses of medications required to induce perioperative anesthesia were higher for social drinkers than for nondrinkers.13 Another study found that patients who consumed more than 70 g of alcohol a day for at least 3 years required significantly more opiates than nondrinkers to achieve adequate analgesia.14

Because of similarities in pathophysiology, the stress responses of surgery and AWS have additive effects. The surgical stress response triggers multiple physiologic changes, including increased heart rate, elevated blood pressure, and increased plasma catecholamine levels. The severity of withdrawal symptoms also can be correlated with plasma catecholamine levels.15 Patients with AUDs show increased responses to surgical stress compared with normal controls.16 Increased frequency of bleeding episodes requiring transfusion has been observed postoperatively in patients with AUDs.16,17 Patients with AUDs who experience intraoperative episodes of hypoxemia or hypotension are also more susceptible to postoperative delirium.18

Postoperative complications and assessment

Patients with AUDs require close attention during the postoperative period to detect AWS and minimize complications. Several studies have compared patients with AUDs to normal controls or social drinkers and demonstrated increased postoperative morbidity and mortality among patients with AUDs. Compared with patients without AUDs, surgical patients with AUDs have prolonged stays in the intensive care unit and hospital.

A review of studies of postoperative complications found that infections, bleeding, and cardiopulmonary insufficiency were the most common complications of patients with AUDs.19 Several pathogenic mechanisms for increased complications in patients with AUDs have been proposed, including immune incompetence, cardiac disease, hemostatic imbalance, and impaired wound healing.

Chronic alcohol abuse is a known cause of cardiomyopathy, and patients with AUDs have decreased preoperative ejection fractions compared with controls.10 Depressed cardiac function may predispose patients to increased postoperative isch-emia and arrhythmias. Perioperative arrhythmias can develop in patients with AUDs without preexisting cardiac disease. Holiday heart syndrome refers to arrhythmias classically occurring after episodes of binge drinking.

Significantly higher bleeding times and an increased frequency of bleeding episodes requiring transfusion have been observed postoperatively in patients with AUDs. Alcohol abuse is an independent risk factor for surgical site infections. Chronic alcohol use decreases T-cell activity and proliferation, which may slow surgical wound healing among patients with significant alcohol consumption.

It can be difficult to diagnose AWS and establish the severity of symptoms in the postoperative period. Postoperative delirium is common. The agitation commonly seen in AWS may be falsely attributed to postoperative pain, use of restraints, medications, or continued intubation. Similarities in presentation between AWS and other causes of delirium delay treatment of AWS.20 The use of a proper preoperative screening assessment is the best means to differentiate AWS delirium from other types of postoperative delirium.

Treatment of alcohol withdrawal syndrome

The goals of treatment of AWS are to provide relief of symptoms, maintain the patient in a calm, lightly sedated state, and prevent progression of withdrawal symptoms. Treatment of AWS is guided by the severity of AWS signs and symptoms. An objective validated measure of AWS, the revised Clinical Institute Withdrawal Assessment-Alcohol (CIWA-Ar) (figure 1), has been used to measure AWS severity, and its use, along with symptom-triggered benzodiazepine administration, reduces the length of hospital stays.21 Administration of the CIWA-Ar in the postoperative period may be complicated by endotracheal intubation, decreased level of consciousness, or inability to communicate with the clinician.

The Ramsey scale rates the level of responsiveness in patients in the ICU. It can be used to guide medication administration to achieve the optimal level of sedation and symptom control in patients for whom a CIWA-Ar assessment is not possible. Patients able to undergo CIWA-Ar assessment can be treated with symptom-triggered dosing regimens (table 3).

Pharmacologic treatment of AWS through detoxification includes long-acting benzodiazepines and barbiturates. Long-acting benzodiazepines, such as chlordiazepoxide, are most frequently used; however, use of a shorter-acting agent, such as lorazepam, is often preferred for elderly patients or those with preexisting liver disease to prevent excess sedation and respiratory depression. Carbamazepine can be used as an alternative to benzodiazepines. Alcohol seizures can be treated with intravenous benzodiazepines.

Adjuvant therapies for AWS include beta-blockers and clonidine to reduce sympathetic overactivity and decrease cardiovascular complications. All patients receiving AWS treatment should receive thiamine and daily multivitamins to prevent complications of AWS, including Wernicke-Korsakoff syndrome. Patients with AUDs or AWS should be educated regarding the harm of their alcohol consumption. Hospitalization after alcohol-related trauma may be an opportunity for alcohol interventions because patients may be more receptive to recognizing alcohol as a problem and be amenable to further alcohol treatment.

Conclusions

Many patients with AUDs encounter elective and emergent needs for surgery. Identification and treatment of AUDs in the perioperative period may improve surgical outcomes (table 4). Preoperative assessment should include identification of an AUD, determination of the type of AUD, and initiation of treatments such as abstinence, alcohol withdrawal prophylaxis, and detoxification. Perioperatively, physicians need to be aware of the effect of alcohol on analgesic and anesthetic medications. Postoperatively, alcohol detoxification, encouragement of continued abstinence, and transition to rehabilitation are important interventions.

The need for surgery can be a powerful motivator for patients to change their drinking behaviors, and multiple interactions with physicians during the perioperative period have the potential to increase patients' motivation to initiate or later seek treatment for their AUDs.

Dr Gordon is assistant professor of medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. He is a core member of the Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, and the VISN-4 Mental Illness Research, Education and Clinical Center. Dr Olstein is a resident in internal medicine, New York University, New York. Dr Conigliaro is associate professor medicine and director, Program for Quality, Safety and Patient Rights, University of Kentucky Medical Center, Lexington.

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