Severe alcohol withdrawal syndrome in ICU: is propofol a safe option?

Introduction

This study aims to compare the efficacy of midazolam or propofol in severe refractory AWS, to detail characteristics of patients and to test the usefulness of different scores (MELD, Child, APACHE II) in severe AWS.

Methods

Patients admitted to the ICU during a 3-year period for refractory AWS after a failed treatment with benzodiazepines according to a symptom-triggered protocol in the general ward or emergency room were treated with neuroleptics and either midazolam or propofol infusion. Processes that could lead to a confounding delirium were excluded. We retrospectively analysed this cohort of patients.

Results

Fifty patients were reviewed, 85.7% men. Mean age was 49 years. Thirty percent had been previously admitted to the ICU for the same reason. Main reason for alcohol withdrawal was abdominal pain (12.2%). Mean alcohol ingestion was 150 g/day. Mean CHILD/MELD/APACHE score was 6/8.5/13 (24.5% patients had a Child score ≥7). Seventy-three percent of patients developed complications (especially respiratory infections in 19 patients). The most frequent agent found was MSSA and Gram-negative bacilli. Seizures accounted for 38% of patients and hepatic encephalopathy in two. We found no relationship between CHILD or MELD score and rate of intubation, length of stay or complications. Patients with APACHE II >12 at admission had a significant increase in risk of intubation (OR 31.2, P < 0.001). Patients with more than 12 days of stay had a significant risk of intubation (OR 49.7, P < 0.0001). Thirty-five patients received propofol as the first intravenous sedation and 14 midazolam. Only two patients with midazolam required a second intravenous sedation. Conversely, nine (26.47%) patients initially with propofol required a second sedation with midazolam. The propofol group showed a significant increase in incidence of seizures (41.17% vs 21% in midazolam group) and infections (47.1% vs 28%) independent of APACHE score. These findings were more remarkable in the subgroup that needed a second intravenous sedation (66% seizures and 77% infection rate). This group had higher APACHE score and was associated with a greater likelihood of intubation and a significant 2-day increase in length of stay.

Conclusions

Propofol has been proposed as an alternative to benzodiazepines in severe AWS, but it could increase the rate of complications (especially seizures and respiratory infections) that could lead to an increase in the intubation rate and length of stay. The APACHE score could be a predictor for the risk of complications and intubation.