(1592) Symptom-Triggered Phenobarbital Versus Lorazepam for Alcohol Withdrawal Syndrome in Trauma Patients

Introduction: Symptom-triggered lorazepam (LZ) is a standard treatment for alcohol withdrawal syndrome (AWS) in the hospital setting. Recent literature demonstrates that phenobarbital (PHB) given as either adjunctive or primary treatment may be an appropriate treatment option for AWS. Currently, limited evidence exists to support utilizing symptom-triggered PHB in the trauma population. The purpose of this study is to determine the efficacy and safety of symptom-triggered PHB versus LZ dosing for AWS in the trauma patient population using the modified Minnesota Detoxification Scale (mMINDS).

Methods: This retrospective, observational review compared the use of symptom-triggered PHB to LZ in trauma patients admitted to the Trauma Surgical Intensive Care Unit (ICU) or Trauma Stepdown Unit from October 2020 to September 2022. The primary objective was to evaluate a safety composite of respiratory support during ICU or hospital stay for alcohol withdrawal-related indications, hemodynamic instability, and oversedation within seven days of mMINDS protocol initiation. Secondary outcomes included: maximum mMINDS scores on days one, two, and three; average dose per day; need for adjunct therapy; crossover to a different therapy; alcohol withdrawal complications; hospital and ICU length of stay; duration of AWS treatment; need for escalation to the ICU; need for intubation for alcohol withdrawal related indications; duration of mechanical ventilation; incidence of ventilator associated pneumonia; and mortality.

Results: A total of 76 patients were included with 27 in the PHB group and 49 in the LZ group. Significantly more patients in the PHB group experienced safety events compared to LZ (40.7% vs 0%, p < 0.001) with the most common being hypotension (37% vs 0%, p < 0.001) followed by oversedation (18.5% vs 0%, p< 0.004). Two patients required mechanical ventilation due to PHB. No secondary outcomes were statistically significant between the two groups except a higher median cumulative daily dose of PHB (in LZ-equivalents) compared to LZ on protocol day one (13 mg vs 4 mg, p < 0.001), day two (9 mg vs 2 mg, p < 0.001), and day three (9 mg vs 2 mg, p < 0.046).

Conclusions: Symptom-triggered LZ may be safer than symptom-triggered PHB for the treatment of AWS in trauma patients utilizing the mMINDS score.