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Clinical Case Study: Delirium

Tremens r/t Alcohol Withdrawal


Marissa Schriver
Keene State College Dietetic Intern
August 16, 2017
Holy Family 1 of 19 hospitals within the Steward
Health Care System
Hospital
1 of 2 campuses; Methuen and
Haverhill
Methuen, MA
385 beds total

9 Floors: ICU/CCU, Psych (2), General


Medicine, Orthopedic Surgery, Birthing
Center, PACU and Telemetry

Provides inpatient and outpatient


services
Utilize the NCP to deliver evidence-
based MNT to patients
Role of the Work with the multidisciplinary
Registered Dietitian medical team to coordinate on
patient care
at Holy Family Hospital
Assess/ treat nutritionally at-risk
patients
Provide intervention and monitoring
to malnourished patients

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59 y.o. Male
Introducing SM 55 and 178#

BMI: 29.6 - Overweight

UBW: 229# (8/4/16)

51# (22%) wt loss in ~1 year PTA

Mother: T2DM

Father: stroke and cancer

Current everyday smoker

Lives with son and has been on


disability since 2006
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ospital-food_tnb.png
Diet History
Consumed ~8 beers/day but
abstained x2 days PTA

PO intake PTA unclear

Failed SLP eval 8/4/16: Dysphagia


ground w. Honey thick liquid and soft
veggies

Chose to eat soft foods for ease of


intake

Receives VNA services but able to


self feed http://cdn0.wideopencountry.com/wp-content/uploads/2017/04/beer-793x526.jpg
Admission 7/27/17
Admitted to ICU/CCU on account of Delirium Tremens associated with EtOH withdrawal

PMH of: MRSA Labs:


EtOH abuse
C. Diff Na 133 ()
Dysphagia
High Cholesterol Cl 91 ()
MI
Albumin 3.3 ()
PE
AFIB
MDD Medications: Paxil, MVI, folic acid, protonix,
HTN
thiamine pill & injection, vit D3, zyprexa, zocor,
Depression symbicort, advair, plavix, flexeril, cymbalta,
DVT
lopressor
Anxiety
COPD
Current smoker
Pathophysiology
in GABA activity, in activity of
norepinephrine, glutamate, and
dopamine

Receptors previously inhibited by alcohol


are no longer inhibited = CNS
hyperexcitability

Delirium Tremens Past episodes of withdrawal and DTs


lead to increased frequency and severity
AKA DTs or Alcohol
of future episodes
Withdrawal Delirium
Starts 1-5 days post cessation in EtOH
intake in chronic alcoholics

Can develop during a pts stay in the


hospital

5-15% mortality rate


Diagnosis

Most common symptoms: sweating, fever, restlessness, irritability, hallucinations,


tachycardia, hyperthermia, and HTN
Also common: physical substance dependence, tremor, anxiety, dilated pupil,
insomnia, seizures, or shallow breathing
Lab values: abnormal LFTs, abnormal electrolyte values, low Mg, Cr, creatinine
phosphokinase and low P
Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)
< 8 points= mild withdrawal, scores of
9 to 15 points = moderate withdrawal
>15 points = severe withdrawal symptoms and increased risk of delirium
tremens or seizures
Clinical Treatment

Goal: to achieve a calm, but awake state or light sleep from where the patient can be
easily aroused

Medications: Benzodiazepines such as Diazepam, Lorazepam, Oxazepam and


Chlordiazepoxide

Safe and appropriate environment for alcohol detox

Multidisciplinary care approach encompassing medical

and psychological care


MNT Recommendations

Chronic EtOH abuse is frequently associated with malnutrition and gastric


malabsorption

Adequate nutrition and hydration are essential for both physical and mental recovery

Increased nutrient needs but vary based on other cofactors

Vitamins: MVI, Thiamine and Folic acid

Electrolyte balance

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Initial Assessment: 7/28
7/28/17

Assessment: Labs:
NPO K 3.0 ()
Nutrition consult re: pt intubated and
Cr 0.5 ()
required EN support via OGT
Propofol @ 14.6 ml/hr Ca 8.3 ()
GI WNL Albumin 2.6 ()
Estimated needs: 1745 kcal (Penn
State equation), 97g PRO, 2436 mL
H2O and daily MVI, thiamine and folic
acid supplements
7/28/17

Diagnosis: Intervention:
1. Unintended wt. loss related to EtOH Promote with Fiber starting @ 35ml/hr
abuse or another unknown etiology as and increase by 15ml/hr Q4H to goal rate
evidenced by wt. loss of 59# (22%) in of 53ml/hr x 24hrs.
~1yr.
-Include 1pk of Prostat (100 kcal and 15g
2. Inadequate oral intake related to
intubation as evidenced by current PRO)
NPO status, OGT in place and request -If not IV fluids, recommend 230mL FWF
for TF recommendations. Q4H
Monitoring/Evaluation: -TF @ goal provides 1757 kcal (with
Tolerance of TF @ goal rate Propofol and Prostat), 95g PRO (with
Changes in Propofol dosage Prostat) and 2,436 mL total H2O
Possible extubation
Follow-Up: 7/31
7/31/17

Assessment: Labs:
Pt was extubated and required EN
support via NGT 7/28/17 7/31/17

Tolerated TF @ 45ml/hr K 3.0 () K 3.8 (WNL)

Adjusted TF regimen d/t extubation Cr 0.5 () Cr 0.4 ()


and d/c of Propofol
Ca 8.3 () Ca 7.8 ()
CIWA-Ar: 5 Albumin 2.6 () No new
Estimated needs: 1900-2100 kcal, 89- Ammonia 95 ()
95g PRO, 2436 mL H2O and daily MVI,
thiamine and folic acid supplements
7/31/17

Diagnosis: Intervention:
Jevity 1.2 starting @ 35ml/hr and increase
by 15ml/hr Q4H to goal rate of 70ml/hr x
1. Unintended wt. Loss related to EtOH
24hrs.
abuse or another unknown etiology
-If not IV fluids, recommend 180mL FWF
as evidenced by wt. Loss of 59# Q4H
(22%) in ~1yr. -TF @ goal provides 2,016 kcal, 93g PRO
2. Inadequate oral intake related to and 2,436 mL total H2O
pending SLP swallow eval as
evidenced by OGT previously in Monitoring/Evaluation:
place and now NGT in place. Tolerance of TF
SLP eval for ability to advance diet
Ammonia level & mental status
Follow-Up: 8/2
8/2/17

Assessment: 7/28/17 7/31/17 8/2/17


Labs:
New wt of 188# indicating a 10# wt
K 3.0 () K 3.8 BNP 983
gain ?fluid shifts
(WNL) ()
Remains in ICU, extubated but
Cr 0.5 () Cr 0.4 () Cr 0.5 ()
sedated and still receiving TF
Ca 8.3 () Ca 7.8 () Ca 8.9
Tolerating TF @ goal rate with 5 mL
(WNL)
residuals
Albumin No new --
Estimated needs remained the same
2.6 ()
SLP consult in place Ammonia Ammonia
95 () 40 (WNL)
CIWA-Ar: 4 - 16
8/2/17

Diagnosis: Intervention:
Continue Jevity 1.2 @ 70ml/hr x 24hrs
1. Unintended wt. Loss related to EtOH with 180 mL FWF Q4H
abuse or another unknown etiology as If pt passes SLP eval, recommend
evidenced by wt. Loss of 59# (22%) in Cardiac diet
~1yr.
Continue thiamine and folic acid
2. Inadequate oral intake related to
pending SLP swallow eval as Weigh pt weekly
evidenced by OGT previously in place Monitoring/Evaluation:
and now NGT in place. Monitor weight changes to adjust TF
or diet to meet needs
Monitor swallowing ability
Fluid status and BNP to adjust FWF
Follow-Up 8/7:
8/7/17
Assessment:
Pt transferred to Telemetry floor

Irritable, combative and not oriented

Diet changed to Cardiac

PO intake: 25-75%

SLP eval: Cut-up solids, soft vegetables


and thin liquids

Estimated needs: 2,046 kcal, 82g PRO,


2,563mL H2O and daily MVI, thiamine and
folic acid supplements

Labs WNL
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kl_eI4JgWuc/UWtHW96nanI/AAAAAAAAA4M/CHofeAce4SM/s1
8/7/17

Diagnosis: Intervention:
Continue Cardiac diet with cut-up
1. Unintended wt. Loss related to EtOH solids and soft vegetables
abuse or another unknown etiology
Trial Ensure Enlive BID
as evidenced by wt. Loss of 59#
(22%) in ~1yr. Continue MVI, folic acid, thiamine
2. Inadequate oral intake related to and vit. D
decreased mental/ cognitive
function as evidenced by PO intake Monitoring/Evaluation:
25-75%. PO and supplement intake
No BM x 2 days
Reccd bowel regimen
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Evaluation/Reassessment
Summary of Hospital Events 7/28-8/10

1. Alcohol withdrawal: Seroquel and Valium; required one-to-one (8/5) d/t agitation and
change in mental status

2. Delirium tremens

a. Endotracheal intubation: 7/27/2017. Liberated from vent on 7/31/17.

3. PNA: Unasyn

4. AFIB: Cardizem drip, lopressor, aspirin, Plavix, Lipitor and lisinopril

5. Metabolic Encephalopathy

a. Pt remained very confused; given Ativan, Haldol and Seroquel and a psych consult
was ordered
Nutrition Goals

1. Tolerates TF @ goal rate

2. No further wt loss

3. Pt to tolerate diet advance

4. Pt consumes >75% of all meals

5. Pt consumes >75% of supplement

*Pt d/c to Adult Psychiatric Unit on 8/10


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Questions?
Thank you!
References

Bayard, M., Mcintyre, J., Hill, K. R., Woodside, J., & Quillen, J. H. (2004).
Alcohol withdrawal syndrome. American Family Physician, 69(6), 1443-1450.
Retrieved from http://www.aafp.org
Burns, M. J., & Lekawa, M. E. (1994). Delirium tremens (M. R. Pinsky, Ed.).
Retrieved August 14, 2017, from Medscape website:
http://emedicine.medscape.com
Heller, J. L., & Zieve, D. (Eds.). (2017, January 1). Delirium tremens.
Retrieved August 14, 2017, from MedlinePlus website:
https://medlineplus.gov/
Kattimani, S., & Bharadwaj, B. (2013). Clinical management of alcohol
withdrawal: A systematic review. Industrial Psychology Journal, 22(2),
100-108. https://doi.org/10.4103/0972-6748.132914
Trevisan, L. A., Boutros, N., Petrakis, I. L., & Krystal, J. H. (1998).
Complications of alcohol withdrawal. Alcohol Health & Research World,
22(1). Retrieved from https://pubs.niaaa.nih.gov