(958) Clinical Triggers for Dexmedetomidine Initiation to Treat Alcohol Withdrawal Syndrome in the ICU

Introduction: Dexmedetomidine (DEX) has sympatholytic properties that lessens adrenergic hyperactivity present in alcohol withdrawal syndrome (AWS). DEX use is generally restricted to the ICU with limited data on the floor. The objective of this study was to identify clinical triggers for DEX initiation to treat AWS in non-intubated ICU patients to guide the development of a protocol for non-ICU patients.

Methods: Adult ICU patients ≥18 years of age who received DEX for AWS from 2020-2022 were evaluated. Patients were excluded if they required intubation for invasive mechanical ventilation or received DEX for non-AWS indications. Clinical triggers preceding DEX initiation included: heart rate (HR), diastolic blood pressure (DBP), Clinical Institute Withdrawal Assessment for Alcohol revised (CIWA-Ar) total and domain scores, and doses of benzodiazepines and phenobarbital. Data are presented as median (IQR) or number (%).

Results: Of the 204 patients screened, 148 (73%) were excluded because they were intubated and 8 (4%) because DEX was used for non-AWS indications, leaving 48 (24%) evaluable patients. Most were male (36, 75%), Caucasian (43, 90%) and non-Hispanic/Latino (47, 98%). Prior to starting DEX, the median HR was 99 (87-110) beats per minute, and DBP was 89 (76-101) mmHg. Total CIWA-Ar score was 14 (8-18), and the highest scoring domains were anxiety (4, 2-4), agitation (3, 1-4), hallucinations (3, 0-4), and clouded sensorium (2, 1-3). CIWA-Ar domains scoring zero included nausea and vomiting (0, 0-0), headache (0, 0-1), tremor (0, 0-3), and sweating (0, 0-2). Phenobarbital was given to 28 (58%) patients before DEX at a dose of 956 (717-1349) mg or 12 (9-19) mg/kg. Benzodiazepines were given to 31 (65%) patients (1 midazolam, 28 lorazepam, 2 both) at a dose of 4 (2-14) mg lorazepam-equivalents. Both phenobarbital and benzodiazepines were given to 21 (44%) patients

Conclusions: Clinical triggers to initiate DEX to treat AWS in non-intubated ICU patients may include a heart rate of 100 beats per minutes, diastolic blood pressure of 90 mmHg, and a total CIWA-Ar score of 14 with an adrenergic hyperactivity predominance. More than half may require phenobarbital and benzodiazepines prior to DEX initiation. These results will guide the development of a protocol for DEX use in non-ICU areas for AWS.