<h4>Importance</h4>Although severe alcohol withdrawal syndrome (SAWS) is associated with substantial morbidity and mortality, most at-risk patients will not develop this syndrome. Predicting its occurrence is important because the mortality rate is high when untreated.<h4>Objective</h4>To assess the accuracy and predictive value of symptoms and signs for identifying hospitalized patients at risk of SAWS, defined as delirium tremens, withdrawal seizure, or clinically diagnosed severe withdrawal.<h4>Data sources</h4>MEDLINE and EMBASE (1946-January 2018) were searched for articles investigating symptoms and signs predictive of SAWS in adults. Reference lists of retrieved articles were also searched.<h4>Study selection</h4>Original studies that were included compared symptoms, signs, and risk assessment tools among patients who developed SAWS and patients who did not.<h4>Data extraction and synthesis</h4>Data were extracted and used to calculate likelihood ratios (LRs), sensitivity, and specificity. A meta-analysis was performed to calculate summary LR.<h4>Results</h4>Of 530 identified studies, 14 high-quality studies that included 71 295 patients and 1355 relevant cases of SAWS (1051 cases), seizure (53 cases), or delirium tremens (251 cases) were analyzed. A history of delirium tremens (LR, 2.9 [95% CI 1.7-5.2]) and baseline systolic blood pressure 140 mm Hg or higher (LR, 1.7 [95% CI, 1.3-2.3) were associated with an increased likelihood of SAWS. No single symptom or sign was associated with exclusion of SAWS. Six high-quality studies evaluated combinations of clinical findings and were useful for identifying patients in acute care facilities at high risk of developing SAWS. Of these combinations, the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) was most useful, with an LR of 174 (95% CI, 43-696; specificity, 0.93) when patients had 4 or more individual findings and an LR of 0.07 (95% CI, 0.02-0.26; sensitivity, 0.99) when there were 3 or fewer findings.<h4>Conclusions and relevance</h4>Assessment tools that use a combination of symptoms and signs are useful for identifying patients at risk of developing severe alcohol withdrawal syndrome. Most studies of these tools were not fully validated, limiting their generalizability.

AbstractBecause of the high incidence of alcoholism in patients with cancer of the laryngopharynx and oral cavity, alcoholic withdrawal syndromes are a frequent postoperative complication in head and neck surgery. Delirium tremens, the most severe form of alcohol withdrawal, is characterized by a progressive symptom complex: anxiety, irritability, confusion, nausea, tremors, hallucinations, hyperpyrexia, convulsions, and delirium. It usually develops 48‐72 hours after the abrupt cessation of prolonged heavy alcoholic drinking but it may occur up to 10 days later. Delirium tremens usually persists for two or three days but there is considerable individual variation in the severity and the intensity of the reaction.Delirium tremens is caused by a rapidly falling blood alcohol level but the exact pathophysiological mechanism is unknown. Numerous theories have been proposed. Walder, et al., feel that one of the breakdown products of ethanol, possibly acetaldehyde, is the cause based on recent hemodialysis studies. Mays, et al., feel that an elevated serum free fatty acid level is causative. Albumin usually binds the fatty acids but when the albumin levels are low, the fatty acids circulate freely and are cytotoxic.In head and neck surgery, delirium tremens usually occurs in the postoperative period. An early diagnosis is difficult because the symptoms usually begin subtly on the second to fourth postsurgical day with agitation and confusion. Twenty‐four hours later when hallucinations, convulsions and delirium occur, the diagnosis is self‐evident.Except for hemodialysis therapy which is complex and not universally available, the treatment of delirium tremens is largely symptomatic and supportive but should begin promptly to minimize or prevent the later more severe symptoms. Paraldehyde and the psychotropic drugs such as chlordiazepoxide (librium) and diazepan (valium) are the most commonly used sedatives. The use of intravenous alcohol is contraindicated because of its short duration of action and narrow margin of safety. Maintaining proper fluid and electrolyte balance is most important. Since some alcoholic patients are dehydrated and some over‐hydrated, the usual parameters and indices for fluid and electrolyte replacement must be closely observed. Restraints, urinary catheters and close observation for lung, liver and gastrointestinal complications are necessary.The irrational, hallucinating, combative and delirious patient is difficult to manage in the postoperative period and is prone to many complications. Needles, feeding tubes, drainage tubes, tracheotomy tubes, wounds, dressings and skin flaps may be molested or removed. Optimum body positioning is impossible. Tracheal aspirations are increased and pneumonitis is likely. Sudden death from fatty emboli is possible.The mortality rate for delirium tremens is approximately 10 percent and when a complicating medical or surgical problem co‐exists, the mortality rate increases to 25 percent. Several case reports are presented to illustrate that delirium tremens in the postoperative period is not only a serious threat to the patient but a difficult challenge for the physician.In order to minimize the high postoperative morbidity and mortality of delirium tremens, the head and neck surgeon should be suspicious of the alcoholic patient, recognize the high risk patient, delay surgery when necessary and begin withdrawal therapy promptly.

Background: Alcohol withdrawal syndrome (AWS) is a frequent presentation in patients with alcohol dependence syndrome. Complicated alcohol withdrawal state (i.e., delirium and/or convulsions) is the most severe form with significant morbidity and mortality if left untreated. Therefore, it is imperative to identify the risk factors associated with complicated AWS for early diagnosis and swift management. Materials and Methods: This study utilized a cross sectional design in a tertiary care center on 60 patients to identify the risk factors associated with complicated alcohol withdrawal. The data collected were subsequently subjected to statistical analysis with appropriate tests (Pearson Chi-square test, t-test). Results: Out of the 60 patients, 30 developed complicated AWS. Amongst the demographic variables, patients with education <10th standard, unemployment and history of delirium tremens were found to be significant predictors of complicated AWS. Patients with complicated AWS consumed higher mean ± standard deviation (19.33 ± 1.77 vs. 11.87 ± 1.17) units of alcohol per day (P < 0.001). The duration of alcohol withdrawal lasted for 7.13 ± 4.17 days in complicated AWS compared to 5.23 ± 2.70 days in uncomplicated (P = 0.041). Tacycardia (P = 0.001), respiratory rate (P = 0.001), low platelet count (P < 0.001) and higher Erythrocyte sedimentaion rate (P < 0.001) were also found to be significant predictors of complicated AWS. Serum gamma-glutamyl transferase GGT values were higher in complicated AWS but the difference was not statistically significant. Conclusion: This study found lower education, unemployment, history of delirium tremens, higher units of alcohol consumed per day, tacycardia, higher respiratory rate, lower platelet count and higher erythrocyte sedimentaion rate as significant predictors of complicated AWS.

There is an increasing awareness of the link between chronic alcohol consumption and the development of cognitive, behavioural and functional deficits. Currently, preventative strategies are limited and require engagement in dedicated long-term rehabilitation and sobriety services, the availability of which is low. The acute alcohol withdrawal syndrome is an episode of neurochemical imbalance leading to autonomic dysregulation, increased seizure risk and cognitive disorientation. In addition to harm from symptoms of alcohol withdrawal (e.g. seizures), the underpinning neurochemical changes may also lead to cytotoxicity through various cellular mechanisms, which long-term, may translate to some of the cognitive impairments observed in Alcohol-Related Brain Damage (ARBD). Here we review some of the pharmacological and neurochemical mechanisms underpinning alcohol withdrawal. We discuss the cellular and pharmacological basis of various potential neuroprotective strategies that warrant further exploration in clinical populations with a view to preventing the development of ARBD. Such strategies, when integrated into the clinical management of acute alcohol withdrawal, may impact large populations of individuals, who currently face limited dedicated service delivery and healthcare resource.

Background Alcohol withdrawal syndrome (AWS) carries a high risk of morbidity and mortality that often requires critical care admission and monitoring. Dexmedetomidine is a known sedative that can help with patient symptoms and potentially reduce Clinical Institute Withdrawal Assessment of Alcohol Scale Revised (CIWA-Ar) scores. This study looks at two groups - the use of dexmedetomidine versus non-dexmedetomidine - in the management of AWS patients to assess the length of intensive care unit (ICU) stay, length of stay (LOS) in hospital, mortality and readmission rate. Methods This retrospective cohort study was conducted at Geisinger Health System, a tertiary care, academic health care system, between January 2016 and December 2022. This study did not require ethics approval according to the Institutional Review Board (IRB). The patients assessed included those aged 18 years or older with a documented CIWA-Ar score requiring admission to the ICU or ICU step-down unit. Exclusion criteria included ICU admission for alternative indications, a prior history of seizure disorder, or patients who left against medical advice. Results A total of 994 patients were identified to have met the inclusion criteria; 371 patients were in the non-dexmedetomidine group and 623 in the dexmedetomidine group. Primary outcomes assessed were hospital LOS (5.0 (3.0 - 9.0) vs. 10 (6.0 - 16.0), P < 0.0001) and days in the ICU (1.9 (1.0 - 3.4) vs. 4.9 (2.9 - 9.0), P < 0.0001), respectively. Secondary outcomes assessed were lorazepam equivalent usage, and readmission within 30, 60 and 90 days, which were not statistically significant when accounting for ICU LOS. Conclusions Among patients treated for AWS, dexmedetomidine use appeared to be associated with longer hospital and ICU stays, while benzodiazepine requirements remained unchanged. These associations may reflect differences in illness severity, emphasizing the need for future prospective evaluation.

Delirium tremens (DT) is a severe form of alcohol withdrawal that can be fatal if not recognized early and treated appropriately. In our study, we aimed to determine the role of neutrophil-lymphocyte ratio (NLR), a marker of systemic inflammation, in predicting the development of DT. This retrospective study was conducted in an alcohol and drug treatment center between March 2017 and March 2020. A total of 212 patients with a diagnosis of alcohol use disorder who were admitted to a special care unit after alcohol withdrawal were included. Blood tests were collected within 24 h of the patients' admission. Comparisons were made according to whether the patients developed DT during the hospitalization. DT was diagnosed in 24.1% of the patients. It was determined that higher NLR level (odds ratio [OR]: 4.38, 95% CI: 2.58-7.43) and history of DT (OR: 1.33, 95% CI: 1.23-11.73) are independent risk factors for the development of DT in the logistic regression analysis. The optimal cut-off value of NLR in predicting DT was 2.67 (sensitivity: 82.4%; specificity: 88.8%). The receiver operating characteristic (ROC) curve of NLR showed a larger area under the curve (AUC) than the curves of other systemic inflammation markers. NLR is a simple, practical, and inexpensive marker that can predict the development of DT in patients with alcohol withdrawal syndrome (AWS).