Surely the NEJM could do a better review of delirium tremens
December 17, 2014, 10:25 pm
Recognition and Management of Withdrawal Delirium (Delirium Tremens). Schuckit MA. N Engl J Med 2014 Nov 27;371:2109-2113.
No abstract available
This is an amazingly inept paper, even by the traditionally low standards of the New England Journal‘s “Review Article” section. It was written by a psychiatrist who — on the basis of this piece — seems not to deal with severe alcohol withdrawal or delirium tremens at all.
At times, the author does not appear to appreciate the serious nature of DTs and the difficulty of treating the condition adequately. For instance, he states that “treatment is best carried out in a locked inpatient ward or an ICU.” I would suggest that the thought of managing a patient with DTs in a locked (presumably psychiatric) ward is — to use the technical term — nuts.
But Dr. Schuckit is not done. Later on he writes:
“The doses needed to control agitation and insomnia vary dramatically among patients and can be prodigious (e.g., >2000 mg of diazepam in the first 2 days in some patients); this underscores the advisability of providing treatment in a hospital, preferably in an ICU.”
Excuse me? It is only “advisable” to treat DTs in the hospital? I’d say it’s damned mandatory. It is just beyond me why the author does not say simply: “Patients should be treated in the ICU.” Full stop.
Although the author does say that the patient should be worked-up for co-morbid and contributing conditions, he gives little guidance on how to go about this evaluation. He does not mention the importance of ruling-out hypoglycemia, trauma, infection or specific electrolyte abnormalities. Although he recommends administering thiamine to patients with suspected Wernicke’s encelphalopathy, he does not describe the findings that would lead to such suspicion.
There is some useful information in the article about the time course of alcohol withdrawal and DTs, the revised CIWA Assessment Scale, and various treatment regimens. I appreciate that he stressed the importance of administering (if required) hefty doses of benzodiazepines, and gave short shrift to newer adjunctive agents such as dexmedetomidine.
It is a shame that the article appears to have received no input from a medical toxicology, emergency practitioner, or critical care specialist, who could have brought up crucial issues that the article blithely ignores. in the end, the author concludes:
Data on the most effective care for patients with withdrawal delirium are lacking. Since the low potential of profit from this research may undercut interest from pharmaceutical companies, treatment trials sponsored by the National Institutes of Health are warranted.”
Good luck with that one.