Here’s an entertaining but insightful peek into the issues surrounding good vs bad science. It’s pitched to the lay public, but brings up a lot of the issues about the pressures of publishing, vagaries of study design, and why things get reported the way they do. Well worth the time (and laughs) to watch!
The post entitled “CIWA Demystified” is one of the most popular on this blog. This type of symptom triggered therapy for alcohol withdrawal applies some degree of objectivity to a somewhat subjective problem. However, it is possible to take it too far.
A retrospective review of registry patients who received CIWA guided therapy was performed. A total of 124 records were reviewed for appropriateness of CIWA useand adverse events. They found that only about half of patients (48%) met both usage criteria (able to communicate verbally, recent alcohol use). And 31% did not meet either criterion! There were 55 nondrinkers in this study, and even though 64% of them could communicate that fact, they were placed on the protocol anyway! Eleven patients suffered adverse events (delirium tremens, seizures, death). Four of them did not meet criteria for use of the protocol.
Bottom line: In order to be placed on the CIWA protocol, a patient must have a recent history of alcohol use, and must be able to communicate verbally. Some physicians assume that patients with autonomic hyperactivity or psychological distress are withdrawing and order the CIWA protocol. This can cover up other causes of delirium, or may make it worse by administering benzodiazepines. This represents inappropriate use of the protocol!
Reference: Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general hospital. Mayo Clin Proc 83(3):274-279, 2008.
What exactly is the CIWA protocol?
It is a tool used commonly in the US that helps clinicians assess and treat potential alcohol withdrawal. A significant amount of injury in this country is due to the overuse of alcohol. A subset of these patients are admitted and do not have access to alcohol. They may begin to withdraw within a few days, and this condition can lead to dangerous complications.
The Clinical Institute Withdrawal Assessment measures 10 items that are associated with withdrawal:
- Nausea / vomiting
- Paroxysmal sweats
- Tactile disturbances (itching, bugs crawling on skin, etc)
- Visual disturbances
- Auditory disturbances
All items are measured on a scale of 0-7 with the exception of orientation, which uses a scale of 0-4. All subscores are tallied to arrive at the final score.
The total score is used to determine whether benzodiazepines should be given to ameliorate symptoms or avoid seizures. Typically, a threshold is selected (8 or 10) and no medications are needed as long as the patient is under it. Once it is exceeded, graduated doses of lorazepam or diazepam are given and vital signs and CIWA scores are repeated regularly. The protocol is discontinued once the patient has three determinations that are under the threshold.
The individual dosing scale and monitoring routine varies by hospital. Look at your hospital policy manual to get specifics for your institution.
Tomorrow, precautions when using the CIWA protocol.
Here are a few references for some of the significant work on REBOA. Be aware that new research is now being published every month! Good luck keeping up!
1. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma 71(6):1869-1872, 2011.
2. A novel fluoroscopy-free, resuscitative endovascular aortic balloon occlusion system in a model of hemorrhagic shock. J Trauma 75(1):122-128, 2013.
3. Survival of severe blunt trauma patients treated with resuscitative endovascular balloon occlusion of the aorta compared with propensity score-adjusted untreated patients. J Trauma 78(4):721-728, 2015.
4. Evaluation of the safety and feasibility of resuscitative endovascular balloon occlusion of the aorta. J Trauma 78(5):897-023, 2015.
5. The role of REBOA in the control of exsanguinating torso hemorrhage. J Trauma 78(5):1054-1058, 2015.
6. Resuscitative endovascular balloon occlusion of the aorta. Resuscitation 96:275-279, 2015.
Direct links to the REBOA series:
We are now entering the “golden age” of REBOA. A number of small, single-institution studies are beginning to appear, most of which tout reasonably positive results. And enough articles are now available to even support a few authors seeking to publish review articles.
Yes, REBOA shows a great deal of promise. But there are a lot of details yet to be worked out. Here are some of the items on the REBOA “questions to answer” list:
- What are the best indications (and contraindications) when considering this highly invasive technique? You will notice that I only listed general indications here. There is some agreement at the major REBOA centers in the US, but there are a lot of differences of opinion as well.
- What kind of training is required to assure competence with this technique?
- What kind of experience, supervision, performance standards should be required for credentialing?
- What about the anatomic, physiologic, and metabolic complications of this technique?
- How long can the catheter be left in place?
- What kind of monitoring is required to assure limb and overall patient safety?
- What about the inevitable technical improvements that are ongoing? In only a few years we have moved from 12 Fr catheters to 7 Fr. From guidewire systems to wireless ones. Expect numerous advancements that will reduce complications and improve survival.
Bottom line: This is a very exciting new technique. But we are still very early in the REBOA life cycle. Everybody wants to be doing the next great thing, but be careful! We are still working with a huge knowledge deficit, and additional published work is essential. If you are working outside of an established REBOA center, I highly recommend you do two things. First, get some training for this complicated technique (see page 1). And don’t let your experience go to waste. Design or join a good study that will contribute to the global knowledge base on REBOA.
Tomorrow: References (if you want to look this stuff up)
Direct links to the REBOA series: