From: Stephanie Terry
To: Pharmacists
Sent: Wednesday, February 14, 2018 7:50:03 AM
Subject: *NEW* ICU Severe Alcohol Withdrawal Orders PILOT Protocol
Attachment: Severe AWS Protocol Pilot Flow Sheet - Pharmacists Verification

Pharmacists,

Please be aware there is a new PILOT protocol (approved by P&T) for MICU patients (at main) with severe alcohol withdrawal syndrome. This protocol will be used by Dr. Humphrey and his UAB resident team as well as the hospitalist group. It utilizes benzodiazepines as well as phenobarbital for benzodiazepine resistant patients. The protocol with PharmD verification tips is attached. Be on the lookout for the new order set when verifying orders.

• The Severe Alcohol Withdrawal Protocol is a PILOT for MICU patients ONLY

• If a physician writes for this order set in a unit that is NOT MICU, please use the standard Alcohol Withdrawal Order Set available on the pulse page

• This protocol is NOT in iCare or on the pulse page (med orders are entered manually by HUA)

• The protocol can be found in both MICUs (4NE and 4MST) in the filing cabinets by the HUA desks

• Please discontinue all other prior orders for sedative/hypnotics when implementing this protocol

• **ALL PHENOBARBITAL AND BENZODIAZEPINE ORDERS WILL BE PRN**

• This protocol utilizes a nurse driven dose escalation of benzodiazepines q30 min PRN (using a flow sheet) until a patient specific effective dose is determined

• If a patient is benzodiazepine resistant (defined as RASS >0 after 8 doses of a benzodiazepine),  phenobarbital dose escalation will be utilized

• RN will follow a dose escalation flow sheet to determine a patient specific effective dose (of either a benzodiazepine OR phenobarbital)

• RN/HUA will fax the completed flow sheet when a patient specific effective dose is determined (they will not fax the sheet after each dose!)

• When a patient specific effective dose of EITHER a benzodiazepine OR phenobarbital (for benzodiazepine resistant patients) is determined – please verify this q4h PRN effective dose order and discontinue all other prior sedative/hypnotic/benzodiazepine/phenobarbital orders

• See attachment

• In summary, when receiving this protocol please verify:

• All other sedative/hypnotics are discontinued

• IV fluid order - if MD desires

• Adult Electrolyte Protocol

• An order for a benzodiazepine; max 8 doses

• Due to the shortage of diazePAM  – please encourage use of LORazepam or midazolam

• An order for phenobarbital 65 - 260 mg IV q30 min PRN RASS>0; max 4 doses (vial size will be 65 mg/mL for the PRN order)

• RN will only use this order for patients resistant to benzodiazepines

• Vitamin replacement order (IV or PO) – if MD desires

• After an RN completes the dose escalation of benzodiazepines (or phenobarbital if patient is benzodiazepine resistant) they will fax you the  flow sheet with a patient specific effective dose of either a benzodiazepine or phenobarbital

• When receiving the RN flow sheet with a “patient specific effective dose”, please discontinue previous benzodiazepine/phenobarbital orders and verify the q4h PRN order for the patient specific dose of either a benzodiazepine OR phenobarbital if the patient was benzodiazepine resistant PLUS a once BREAKTHROUGH dose order

Background: The guidelines for treatment of acute alcohol withdrawal syndrome (AWS) are dated and were last published in 1997. More recently published data (post-guideline) suggests our institution is undertreating severe AWS. Our current AWS protocol is non-aggressive and is undertreating patients with severe AWS. Newer, and more aggressive, benzodiazepine dosing strategies have shown decreased ICU length of stay, need for and length of mechanical ventilation, need for continuous infusions of benzodiazepines, and duration of sedation. This more effective dosing strategy is being used widely across several hospital systems. Newer literature supports a symptom-triggered dose escalation approach to dosing benzodiazepines for severe AWS in ICU patients. The IRC has approved data collection for patients undergoing this pilot protocol and depending on the results, this protocol could be a new standard for Cerner (similar to how the SAD protocol came about). Results from this pilot protocol will also be presented at the Pharmacy Southeastern Residency Conference in April 2018. 

PLEASE CONTACT: Stephanie Terry, Nellie McKee, or Mickala Thompson with any questions regarding this new pilot protocol. Thanks for all you do! 

Stephanie Terry, Pharm.D.
PGY-1 Pharmacy Resident