RESUMO
OBJECTIVES: We sought to determine occurrence, predictors, and prognosis of alcohol withdrawal syndrome and delirium tremens in patients with traumatic injury. DESIGN: Retrospective multicenter cohort study. SETTING: Three U.S. trauma centers. PATIENTS: Twenty-eight thousand one hundred one trauma patients admitted from 2010-2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Measures included occurrence of alcohol withdrawal syndrome and delirium tremens, injury characteristics, risk factors for alcohol withdrawal syndrome, clinical outcomes, pharmacologic treatment for alcohol withdrawal syndrome, and Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) scores. Alcohol withdrawal syndrome severity was defined by CIWA-Ar score as minimal (< 10), moderate (10-20), and severe (> 20). Alcohol withdrawal syndrome developed in 0.88% (n = 246), including 12% minimal, 36% moderate, and 53% severe. Alcohol withdrawal syndrome progressed to delirium tremens in 11%. Before adjustment, alcohol withdrawal syndrome severity was associated with injury severity, hypokalemia, baseline CIWA-Ar score, and established alcohol withdrawal syndrome risk factors. Logistic regression identified the following predictors of delirium tremens: baseline CIWA-Ar score greater than or equal to 10 (odds ratio, 6.05; p = 0.02) and age greater than or equal to 55 (odds ratio, 3.24; p = 0.03). In patients with severe alcohol withdrawal syndrome, severe head injury also predicted progression to delirium tremens (odds ratio, 6.08; p = 0.01), and hypokalemia was borderline significant (odds ratio, 3.23; p = 0.07). Clinical outcomes of hospital length of stay, ICU length of stay, and alcohol withdrawal syndrome complications differed significantly by alcohol withdrawal syndrome severity and were worse with more severe manifestations of alcohol withdrawal syndrome. Mortality also significantly differed by alcohol withdrawal syndrome severity but was only greater in patients who progressed to delirium tremens (11.1%; p = 0.02); otherwise, there were no differences in mortality by severity (4%, 4%, and 0% by minimal, moderate, and severe alcohol withdrawal syndrome). CONCLUSIONS: Trauma patients with alcohol withdrawal syndrome experience a high occurrence of delirium tremens that is associated with significant mortality. These data demonstrate the predictive ability of baseline CIWA-Ar score, age, and severe head injury for developing delirium tremens.
Assuntos
Transtornos Induzidos por Álcool/epidemiologia , Síndrome de Abstinência a Substâncias/epidemiologia , Centros de Traumatologia/estatística & dados numéricos , Ferimentos e Lesões/epidemiologia , Adulto , Fatores Etários , Delirium por Abstinência Alcoólica/epidemiologia , Delirium por Abstinência Alcoólica/fisiopatologia , Transtornos Induzidos por Álcool/diagnóstico , Transtornos Induzidos por Álcool/fisiopatologia , Concentração Alcoólica no Sangue , Traumatismos Craniocerebrais/epidemiologia , Feminino , Humanos , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores Sexuais , Síndrome de Abstinência a Substâncias/diagnóstico , Síndrome de Abstinência a Substâncias/fisiopatologia , Índices de Gravidade do Trauma , Sinais VitaisRESUMO
O objetivo deste artigo é o de revisar e descrever as principais alteracões neurofarmacológicas causadas pela exposicão crônica ao álcool, assim como os fenômenos ocorridos durante o período de abstinência. São apresentados dados referentes às alteracões neuroadaptativas e de tolerância ocorridas nos principais sistemas de monoaminas, aminoácidos neurotransmissores e canais de cálcio, o que está relacionado a uma piora no prognóstico de portadores de comorbidades psiquiátricas com o consumo de álcool. São também descritos alguns estudos relevantes que demonstram o envolvimento de outros mecanismos de acão do álcool no sistema nervoso central, como o envolvimento de opióides, entre outras substâncias. O artigo reafirma a importância, para clínicos e pesquisadores, de um sempre maior entendimento do mecanismo de acão central do álcool, pois dele depende a busca por novas opcões farmacológicas, tanto para a reducão dos danos provocados pelo seu uso crônico, como para o tratamento da síndrome de abstinência a esta substância.
Assuntos
Humanos , Delirium por Abstinência Alcoólica/metabolismo , Alcoolismo/metabolismo , Neurotransmissores/metabolismo , Delirium por Abstinência Alcoólica/fisiopatologia , Intoxicação Alcoólica/metabolismo , Intoxicação Alcoólica/fisiopatologia , Alcoolismo/fisiopatologia , Etanol/metabolismoRESUMO
The objective of this paper is to review and describe the main neuropharmacological changes caused by the chronic use of alcohol and those observed during its withdrawal period. The results show international data referring to the involvement of monoamine systems, neurotransmitters and calcium channels in both neuroadaptation and tolerance to alcohol effects and withdrawal. Relevant studies showing the participation of other systems in those mechanisms, as opioids and other substances, are also shown. The article reinforces the importance, for both physicians and researchers, of an always growing understanding of alcohol central mechanisms of action. This understanding is necessary to new pharmacological options to alcohol harm reduction as well as to alcohol withdrawal treatment.