Eliminating the benzos: A benzodiazepine-sparing approach to preventing and treating alcohol withdrawal syndrome.

BACKGROUND: Alcohol withdrawal syndrome (AWS) represents significant cost to the hospitalized trauma population from a clinical and financial perspective. Historically, AWS has been managed with benzodiazepines. Despite their efficacy, benzodiazepines carry a heavy adverse effect profile. Recently, benzodiazepine-sparing protocols for the prophylaxis and treatment of AWS have been used in medical patient populations. Most existing benzodiazepine-sparing protocols use phenobarbital, while ours primarily uses gabapentin and clonidine, and no such protocol has been developed and examined for safety and efficacy specifically within a trauma population. METHODS: In December of 2019, we implemented our benzodiazepine-sparing protocol for trauma patients identified at risk for alcohol withdrawal on admission. Trauma patients at risk for AWS admitted to an academic Level 1 trauma center before (conventional) and after (benzodiazepine-sparing [BS]) protocol implementation were compared. Outcomes examined include morphine milligram equivalent dosing rates and lorazepam equivalent dosing rates as well as the Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scores, hospital length of stay, intensive care unit length of stay, and ventilator days. RESULTS: A total of 387 conventional and 134 benzodiazepine sparing patients were compared. Injury Severity Score (13 vs. 16, p = 0.10) and admission alcohol levels (99 vs. 149, p = 0.06) were similar. Patients in the BS pathway had a lower maximum daily CIWA-Ar (2.7 vs. 1.5, p = 0.04). While mean morphine milligram equivalent per day was not different between groups (31.5 vs. 33.6, p = 0.49), mean lorazepam equivalents per day was significantly lower in the BS group (1.1 vs. 0.2, p < 0.01). Length of stay and vent days were not different between the groups. CONCLUSION: Implementation of a benzodiazepine-sparing pathway that uses primarily clonidine and gabapentin to prevent and treat alcohol withdrawal syndrome in trauma patients is safe, reduces the daily maximum CIWA-Ar, and significantly decreases the need for benzodiazepines. Future studies will focus on outcomes affected by avoiding AWS and benzodiazepines in the trauma population. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Penetrating brain injury with hypopituitarism.

A 34-year-old healthy male presented as a trauma activation after sustaining a gunshot wound to his face. CT head imaging was suggestive of a ballistic fragment adjacent to a posterior wall sphenoid sinus fracture with likely a small volume of adjacent blood products. He was ultimately diagnosed with hypopituitarism which included central diabetes insipidus, central hypothyroid, and adrenocorticotropic hormone deficiency secondary to cortisol deficiency. This case illustrates the spectrum of endocrine dysfunction that can occur with skull base injuries, and the appropriate pituitary-function screening and treatment that should be performed if there is clinical concern. Early recognition and prompt treatment of pituitary insufficiency can facilitate overall rehabilitation after TBI.

Weight-Based Enoxaparin Achieves Adequate Anti-Xa Levels More Often in Trauma Patients: A Prospective Study.

BACKGROUND: Previous research demonstrates that twice-daily enoxaparin is inadequate for venous thromboembolic (VTE) prophylaxis in critically ill trauma patients prompting dose adjustment based on anti-Xa levels. Most studies evaluate peak anti-Xa levels; however, data suggest that trough levels are associated with decreased VTE. We evaluated trough anti-Xa levels in noncritically ill trauma patients receiving fixed or weight-based enoxaparin. METHODS: Peak and trough anti-Xa levels were prospectively collected from patients receiving at least 3 consecutive doses of enoxaparin (PRE). A performance improvement project prompted a change to weight-based dosing. Peak and trough levels were subsequently prospectively collected from the weight-based group (POST). Adequate peak was defined as ≥0.2 IU/mL and adequate trough as ≥0.1 IU/mL. PRE and POST groups were compared. RESULTS: 200 patients were evaluated (100 PRE, 100 POST). In the PRE group, only 34% of trough and 61% of peak anti-Xa levels were adequate compared with 82% and 97%, respectively, in the POST group (P < .01). Median trough improved from 0.07 IU/mL to 0.2 IU/mL (P < .01). Median peak improved from 0.22 IU/mL to 0.47 IU/mL (P < .01). More patients achieved adequate peak and trough levels in the POST group (79% vs 31%, P < .01). 95% of patients with adequate troughs also had adequate peaks, whereas 75% with adequate peaks had adequate troughs. DISCUSSION: Traditional enoxaparin dosing in noncritically ill trauma patients results in suboptimal anti-Xa levels. Weight-based enoxaparin improves both trough and peak anti-Xa levels obviating dose adjustment. Furthermore, troughs better predict adequate anti-Xa levels.