Fatores Precipitantes de Delirium em Pacientes Idosos Hospitalizados / Precipitating Factors of Delirium in Elderly Hospitalized / Patients Factores precipitantes del delirio en pacientes ancianos hospitalizados

Objetivo: Caracterizar os fatores precipitantes e modificáveis de delirium em idosos internados acompanhados pela equipe móvel de Geriatria e Gerontologia. Método: estudo transversal, descritivo, exploratório e prospectivo realizado em um hospital de alta complexidade de São Paulo, com idosos hospitalizados. Os dados foram analisados por estatística descritiva. Resultados: foram avaliados 12 idosos, sendo 91,7% do sexo feminino, internados predominantemente em enfermarias cirúrgicas 83,3%. Os fatores precipitantes observados foram os ambientais presentes em 100% dos sujeitos do estudo, sendo possível realizar alguma intervenção em 83,3% dos casos, seguida pela categoria das doenças intercorrentes onde 45,4% dos casos foram passíveis de intervenção. Conclusão: no presente estudo, ao caracterizar os fatores precipitantes e modificáveis de delirium em idosos hospitalizados, espera-se evidenciar a possibilidade da implementação de prevenção e tratamento do quadro apontado, visando despertar os profissionais que atuam na prestação dos cuidados para a relevância do problema

ObjectiveTo characterize the precipitating and modifiable factors of delirium in hospitalized elderly accompanied by the mobile team of Geriatrics and Gerontology. Method: crosssectional, descriptive, exploratory and prospective study conducted in a highly complex hospital in São Paulo, with hospitalized elderly. The data were analyzed using descriptive statistics. Results: 12 elderly people were assessed, 91.7% of whom were female, predominantly hospitalized in surgical wards 83.3%. The precipitating factors observed were the environmental factors present in 100% of the study subjects, and it is possible to perform some intervention in 83.3% of the cases, followed by the category of intercurrent diseases where 45.4% of the cases were subject to intervention. Conclusion: in the present study, by characterizing the precipitating and modifiable factors of delirium in hospitalized elderly people, it is expected to highlight the possibility of implementing prevention and treatment of the mentioned condition, aiming to awaken the professionals who work in the provision of care for the relevance of the problem

Objetivo: Caracterizar los factores desencadenantes y modificables del delirio en ancianos hospitalizados acompañados del equipo móvil de Geriatría y Gerontología. Método: estudio transversal, descriptivo, exploratorio y prospectivo realizado en un hospital de alta complejidad en São Paulo, con ancianos hospitalizados. Los datos se analizaron mediante estadística descriptiva. Resultados: se evaluaron 12 ancianos, 91,7% de sexo femenino, predominantemente hospitalizados en quirófano 83,3%. Los factores precipitantes observados fueron los factores ambientales presentes en el 100% de los sujetos de estudio, siendo posible realizar alguna intervención en el 83,3% de los casos, seguido de la categoría de enfermedades intercurrentes donde el 45,4% de los casos fueron sometidos a intervención. Conclusión: en el presente estudio, al caracterizar los factores precipitantes y modificables del delirio en ancianos hospitalizados, se espera resaltar la posibilidad de implementar la prevención y el tratamiento de la condición mencionada, con el objetivo de despertar a los profesionales que laboran en la prestación de cuidados para la relevancia del problema.

Adjunct Ketamine Use in the Management of Severe Ethanol Withdrawal.

OBJECTIVES: Ketamine offers a plausible mechanism with favorable kinetics in treatment of severe ethanol withdrawal. The purpose of this study is to determine if a treatment guideline using an adjunctive ketamine infusion improves outcomes in patients suffering from severe ethanol withdrawal. DESIGN: Retrospective observational cohort study. SETTING: Academic tertiary care hospital. PATIENTS: Patients admitted to the ICU and diagnosed with delirium tremens by Diagnostic and Statistical Manual of Mental Disorders V criteria. INTERVENTIONS: Pre and post guideline, all patients were treated in a symptom-triggered fashion with benzodiazepines and/or phenobarbital. Postguideline, standard symptom-triggered dosing continued as preguideline, plus, the patient was initiated on an IV ketamine infusion at 0.15-0.3 mg/kg/hr continuously until delirium resolved. Based upon withdrawal severity and degree of agitation, a ketamine bolus (0.3 mg/kg) was provided prior to continuous infusion in some patients. MEASUREMENTS AND MAIN RESULTS: A total of 63 patients were included (29 preguideline; 34 postguideline). Patients treated with ketamine were less likely to be intubated (odds ratio, 0.14; p < 0.01; 95% CI, 0.04-0.49) and had a decreased ICU stay by 2.83 days (95% CI, -5.58 to -0.089; p = 0.043). For ICU days outcome, correlation coefficients were significant for alcohol level and total benzodiazepine dosing. For hospital days outcome, correlation coefficients were significant for patient age, aspartate aminotransferase, and alanine aminotransferase level. Regression revealed the use of ketamine was associated with a nonsignificant decrease in hospital stay by 3.66 days (95% CI, -8.40 to 1.08; p = 0.13). CONCLUSIONS: Mechanistically, adjunctive therapy with ketamine may attenuate the demonstrated neuroexcitatory contribution of N-methyl-D-aspartate receptor stimulation in severe ethanol withdrawal, reduce the need for excessive gamma-aminobutyric acid agonist mediated-sedation, and limit associated morbidity. A ketamine infusion in patients with delirium tremens was associated with reduced gamma-aminobutyric acid agonist requirements, shorter ICU length of stay, lower likelihood of intubation, and a trend toward a shorter hospitalization.

Occurrence, Predictors, and Prognosis of Alcohol Withdrawal Syndrome and Delirium Tremens Following Traumatic Injury.

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.

Manejo del síndrome de abstinencia alcohólica en los pacientes críticos / Management of the syndrome of alcohol withdrawal in critical patients

El manejo del síndrome de abstinencia alcohólica es un desafío en los pacientes críticos. Con frecuencia, se desconocen los antecedentes de consumo de alcohol o este dato es incompleto, lo que limita la identificación de quienes pueden desarrollar este síndrome. El cese abrupto del consumo de alcohol coloca a estos pacientes en alto riesgo de sufrir síndrome de abstinencia alcohólica grave. Típicamente, las benzodiacepinas son consideradas las drogas de primera línea para el manejo de estos casos. Sin embargo, si el paciente progresa a un estado más grave con convulsiones o delirium tremens, puede ser necesario administrar medicación adyuvante a las benzodiacepinas, como el propofol o la dexmedetomidina, o emplear estas últimas drogas como terapias alternativas en aquellos que no responden a las benzodiacepinas. La aparición de convulsiones representa un fuerte factor de riesgo para la progresión a un síndrome de abstinencia alcohólica grave, con el desarrollo posterior de delirium tremens hasta en el 30% de los casos. El delirium tremens es el cuadro más grave y ocurre en el 5-20% de los pacientes con este síndrome, con una mortalidad hasta del 25% sin tratamiento y que se reduce al 0-1% con tratamiento. Es importante conocer el antecedente del consumo de alcohol para evitar el síndrome de abstinencia alcohólica o tratar rápidamente sus síntomas más graves, y mejorar la supervivencia de estos pacientes.(AU)

Alcohol withdrawal syndrome (AWS) is a well-known and a challenging condition occurring in critically ill patients. Frequently, history of alcohol abuse is unknown when the patient is admitted to the intensive care unit, limiting the identification of those who could develop AWS. The abrupt cessation of a heavy or constant drinking put these patients in high risk of suffering from this syndrome in its severe form. Typically, benzodiazepines are considered the first line of treatment. However, if clinical conditions progress to epileptic seizures or delirium tremens or are refractory to benzodiazepines, adjuvant drugs like propofol or dexmedetomidine might be an option to control the severe symptoms. Delirium tremens can occur in up to 30% of patients; it is the most severe picture with a mortality of 25% without treatment and that can be reduced to almost 0-1% with treatment. It is important to appropriately identify alcohol abuse in order to avoid the early clinical manifestations of AWS or rapidly treat its most severe symptoms and improve survival.(AU)

La psiquiatría de enlace y el diagnóstico del delirium tremens / Liaison psychiatry in diagnosing delirium tremens

La manifestación clínica más grave y potencialmente fatal de la abstinencia de alcohol es el delirium tremens (DT), cuadro observado en aproximadamente el 5% al 10% de los pacientes con trastorno por consumo de alcohol que requieren hospitalización. El diagnóstico adecuado del DT requiere conocer los factores de riesgo, el cuadro clínico típico y la evolución y la gravedad de los síntomas de abstinencia. Las benzodiazepinas son el tratamiento farmacológico de elección para los pacientes con DT. Su eficacia fue confirmada mediante numerosos estudios. Si bien hay drogas alternativas que también pueden ser efectivas, las benzodiazepinas son elegidas debido a su perfil farmacocinético y de seguridad favorable. Las drogas alternativas son utilizadas como complemento de las benzodiazepinas para el tratamiento de los pacientes con cuadros de abstinencia complicados o resistentes. Los esquemas que incluyen dosis de carga administradas por vía oral o intravenosa son los preferidos para los pacientes con DT. El aumento rápido de la dosis de benzodiazepinas de acuerdo con la gravedad de los síntomas evaluados mediante escalas estructuradas y el empleo de drogas adyuvantes alternativas permiten el control oportuno del DT. Cerca del 10% de los pacientes que presentan resistencia a las benzodiazepinas requieren tratamiento en unidades de terapia intensiva con dosis intravenosas elevadas de benzodiazepinas y otras drogas, evaluación minuciosa y, de ser necesario, ventilación mecánica. La suplementación vitamínica y la atención adecuada por parte del personal de enfermería también son componentes esenciales del tratamiento. Los psiquiatras de enlace deberían integrar equipos multidisciplinarios destinados al tratamiento agudo de los pacientes con DT. No obstante, solo los psiquiatras de enlace con capacidades y conocimiento que se desempeñan de acuerdo con los protocolos estandarizados pueden lograr que determinados pacientes con DT reciban tratamiento adecuado. El psiquiatra de enlace también debe procurar un periodo de abstinencia seguro que proteja la dignidad del paciente y lo prepare para resolver la dependencia

The most serious and potentially life-threatening manifestation of alcohol withdrawal is delirium tremens (DT) or alcohol withdrawal delirium, which occurs in about 5% to 10% of hospitalized patients with alcohol problems. A consideration of risk factors, the typical clinical picture, evolution of withdrawal-symptoms and their severity aid in the proper recognition of DT. Benzodiazepines are the mainstay of medication treatment of DT. Their efficacy has been established by a large body of evidence. Although alternative medications might be equally effective, benzodiazepines are preferred because of their favourable pharmacokinetic and safety. Alternative medications are used as adjuncts to benzodiazepines in the treatment of complicated and refractory withdrawal states. Oral or intravenous loading-dose regimens are preferred for treatment of DT. Rapidly escalating doses of benzodiazepines titrated to symptom-severity on structured scales and the use of adjunctive alternative medications ensures prompt control of DT. About 10% of patients who are benzodiazepine-resistant require treatment in intensive care units with massive intravenous doses of benzodiazepines and additional medications, careful monitoring and mechanical ventilation if necessary. Vitamin supplementation and adequate medical, nursing and supportive care are other essential components of management. Liaison psychiatrists are expected to form an integral part of the multidisciplinary team, which manages patients with DT in acute-care settings. Only skilled and knowledgeable liaison psychiatrists relying on standardized treatment protocols can make certain that patients with DT receive adequate care. The liaison psychiatrist also needs to ensure a safe and humane withdrawal that protects the patient's dignity and prepares the patient for on-going treatment of dependence.

Influence of microelement concentration on the intensity of alcohol withdrawal syndrome.

AIMS: To establish a nutritional and constitutional profile concerning the micronutrient plasma concentration of patients who suffer from AWS. METHOD: Observational case control study to determine whether patients who exhibited symptoms of AWS (N = 60) had micronutrient plasmatic concentration deficiencies when compared with healthy controls (N = 34). RESULTS: There were statistically significant differences between the concentrations of nutrients that are correlated with glutamate hyperactivity (zinc, magnesium and folate/vitamin B12/homocysteine). CONCLUSION: Evidence from literature and our experiment suggests that brain activity, especially the glutamatergic system, might be directly involved in micronutrient concentrations. Therefore, their supplementation to the AWS patient might improve symptom evolution.

Estudio retrospectivo de cohorte sobre el antecedente de síndrome de abstinencia al alcohol y su asociación con delírium trémens en hospitalizaciones posteriores, Medellín, 2010-2012 / History of alcohol withdrawal syndrome and its association with delirium tremens on later hospitalizations: retrospective cohort study

Introducción: el consumo excesivo de alcohol es un problema de salud pública a nivel mundial que ocasiona anualmente, según la Organización Mundial de la Salud, 2,5 millones de muertes. En Colombia, el 11% de los mayores de 15 años cumple los criterios de abuso de alcohol del DSM-IV, con las consecuencias personales, legales y sociales que este implica, incluyendo las complicaciones asociadas al consumo crónico como el síndrome de abstinencia al alcohol y el delírium trémens. Objetivo: determinar si el antecedente de síndrome de abstinencia al alcohol se asocia con una mayor aparición de delírium trémens en pacientes atendidos por este síndrome en la ciudad de Medellín entre agosto de 2010 y julio de 2012. Materiales y métodos: se realizó un estudio de cohorte retrospectivo, comparando pacientes con y sin antecedente de síndrome de abstinencia al alcohol y el desarrollo de delírium trémens, además de otras posibles asociaciones como disfunción hepática y desequilibrios electrolíticos. El análisis de los datos fue de tipo bivariado, por medio de las pruebas estadísticas c2, Fisher y Mann Whitney. Resultados: se incluyeron 60 pacientes, en las características de base el 67% presentaron síndrome de abstinencia a alcohol, y 22% tuvieron antecedente de delírium trémens. Durante la estancia hospitalaria 56% de los sujetos desarrollaron delírium trémens. El antecedente de síndrome de abstinencia al alcohol no se asoció con desarrollar delírium trémens (p=0,26). En tanto que el antecedente de delírium trémens se comportó como un factor de riesgo para presentarlo nuevamente (p=0,02). Conclusión: el antecedente de síndrome de abstinencia al alcohol no se encontró relacionado con el desarrollo de delírium trémens en hospitalizaciones posteriores, en tanto que el antecedente de delírium trémens está asociado con la aparición de nuevos episodios. (MÉD.UIS. 2014;27(1):17-23).

Introduction: alcohol abuse is a public health problem around the world, which causes 2.5 million deaths per year according to the World Health Organization. In Colombia, 11% of the male population older than 15 years fulfills the DSM-IV criteria for alcohol abuse, with the personal, legal and social consequences that it entails, including those associated with chronic comsumption, such as withdrawal syndrome and delírium trémens. Objective: to establish if the history of alcohol withdrawal syndrome is related to a higher risk for development of delírium trémens in patients treated by this syndrome from the city of Medellin, between August of 2010 and July of 2012. Methods: this is a retrospective cohort study, with a comparison between patients with history of alcohol withdrawal syndrome and patients in their first episode, and the development of delírium trémens and the risk factors related with this. We did a bivariate analysis of the factors with the Mann Whitney, C2 and Fisher test. Results: 67% of the patients had a history of alcohol withdrawal syndrome and 22% showed previous episodes of delírium trémens. During hospitalization 56% of the subjects developed delírium trémens. The study showed that history of withdrawal syndrome is not a risk factor for the appearance of delírium trémens (p=0.26). In contrast, the record of delírium trérmens is a risk for new episodes (p=0.02). Conclusion: the history of alcohol withdrawal syndrome appears not to be a risk factor for the development of delírium trémens in a new hospitalization. On the other hand, the history of delírium trémens was associated with new episodes of delírium. (MÉD.UIS. 2014;27(1):17-23).

Guía de práctica clínica para la detección temprana, diagnóstico y tratamiento de la fase aguda de intoxicación de pacientes con abuso o dependencia del alcohol Parte I: Tamización, detección temprana y factores de riesgo en pacientes con abuso o dependencia del alcohol / Clinical practice guide for early detection, diagnosis and treatment of the acute intoxication phase in patients with alcohol abuse or dependencepart i: screening, early detection and risk factors in patients with alcohol abuse or dependence

Introducción: El alcohol es la segunda sustancia psicotrópica más usada en el mundo y el tercer factor de riesgo para muerte prematura y discapacidad. Su uso nocivo es un problema de salud pública mundial, dado su impacto personal, laboral, familiar, económico y social. Hasta el 70 % de las personas en riesgo de tener problemas con el alcohol no se detectan en la práctica médica, lo que hace pensar que se requieren medidas de tamizaje específicas que permitan la detección temprana y lleven a un tratamiento oportuno. Este artículo presenta la evidencia encontrada en tamización de abuso y dependencia de alcohol y en tamización e identificación de factores de riesgo; también presenta la evidencia relacionada con síndrome de abstinencia, delirium tremens y encefalopatía de Wernicke, con el fin promover una de detección temprana y un tratamiento oportuno. Método: Revisiones sistemáticas de la evidencia disponible y evaluación de las guías pertinentes identificadas en la literatura, para decidir, en cada pregunta, si se adopta o se adapta a una recomendación ya existente, o si se desarrollan recomendaciones de novo. Para las recomendaciones de novo y aquellas adaptadas, se realizó una síntesis de la evidencia, se elaboraron tablas de evidencia y se formularon las recomendaciones basadas en evidencia. Resultados: Se encuentra evidencia y se realizan recomendaciones para tamización pertinente y búsqueda de factores de riesgo, con el fin de realizar un diagnóstico y un manejo oportuno de abuso y dependencia a alcohol y sus complicaciones: síndrome de abstinencia, delirium tremens y encefalopatía de Wernicke...

Introduction: Worldwide, alcohol is the second most-used psychotropic substance and the third risk factor for early death and disability. Its noxious use is a world public health problem given its personal, labor, family, economic and social impact. 70 % of people under risk of having alcohol problems go undetected in medical practice, a fact that underlines the need for specific screening measures allowing early detection leading to timely treatment. This article presents evidence gathered by alcohol abuse and dependence screening as well as by risk factor identification and screening. It also presents evidence concerning withdrawal symptoms, delirium tremens and Wernicke’s encephalopathy in order to promote early detection and timely treatment. Methodology: Systematic revision of the evidence available together with an evaluation of pertinent guidelines found in literature so as to decide whether to adopt or adapt the existing recommendation for each question or to develop de novo recommendations. For de novo recommendations as well as those adapted, it was carried out an evidence synthesis, together with evidence tables and formulation of recommendations based on the evidence. Results: Evidence was found and recommendations were made for the pertinent screening and search of risk factors, in order to perform a diagnosis and carry out a timely management of alcohol abuse, dependence and ensuing complications: withdrawal syndrome, delirium tremens and Wernicke’s encephalopathy...

Guía de práctica clínica para la detección temprana, diagnóstico y tratamiento de la fase aguda de intoxicación de pacientes con abuso o dependencia del alcohol: Parte II: Evaluación y manejo de los pacientes con intoxicación aguda por alcohol / Clinical practice guide for early detection, diagnosis and treatment of the acute intoxication phase in patients with alcohol abuse or dependence Part II: evaluation and management of patients with acute alcohol intoxication

Introducción: El alcohol es la segunda sustancia psicotrópica más usada en el mundo y el tercer factor de riesgo para muerte prematura y discapacidad. Su uso nocivo es un problema de salud pública mundial, dado su impacto personal, laboral, familiar, económico y social. Es de suma importancia la identificación de intoxicación aguda por alcohol, el síndrome de abstinencia alcohólica y sus complicaciones, como delirium tremens y encefalopatía de Wernicke, para garantizar de esta manera un tratamiento oportuno para estos pacientes. Este artículo busca presentar la evidencia encontrada para el abordaje y el tratamiento de estas presentaciones clínicas. Método: Revisiones sistemáticas de la evidencia disponible y se evaluaron las guías pertinentes identificadas en la literatura, para decidir, en cada pregunta, si se adopta o se adapta a una recomendación ya existente, o bien, si se desarrollan recomendaciones de novo. Para las recomendaciones de novo y aquellas adaptadas, se realizó una síntesis de la evidencia, se elaboraron tablas de evidencia y se formularon las recomendaciones basadas en evidencia. Resultados: Se encuentra evidencia y se realizan recomendaciones para abordaje y tratamiento pertinente de intoxicación alcohólica aguda, síndrome de abstinencia, delirium tremens y encefalopatía de Wernicke...

Introduction: Worldwide, alcohol is the second most-used psychotropic substance and the third risk factor for early death and disability. Its noxious use is a world public health problem given its personal, labor, family, economic and social impact. The identification of acute alcohol intoxication is extremely important, as well as the alcohol withdrawal syndrome and its complications, such as delirium tremens and Wernicke’s encephalopathy in order to grant a timely treatment for those patients. This article introduces the evidence found so as to face and treat these clinic manifestations. Methodology: Systematic revision of the evi dence available together with an evaluation of pertinent guidelines found in literature so as to decide whether to adopt or adapt the existing recommendation for each question or to develop de novo recommendations. For de novo recommendations as well as those adapted, it was carried out an evidence synthesis, together with evidence tables and formulation of recommendations based on the evidence. Results: Evidence was found and recommendations were made for the diagnosis and treatment of acute alcohol intoxication, withdrawal syndrome, delirium tremens and Wernicke’s encephalopathy...

Recuperación de la adicción al alcohol: una transformación para promover la salud / Recovering from Alcohol Addiction: A Transformation to Promote Health / Recuperação do vício no álcool: uma transformação para promover a saúde

Se presenta una metasíntesis cuyo objetivo es establecer las características del proceso de recuperación en las personas que tienen adicción al alcohol. La metodología metasintética se fundamenta en la integración e interpretación de los hallazgos de algunos estudios cualitativos que permiten reconocer elementos sustanciales en la creación de nuevas interpretaciones en el fenómeno de recuperación de la adicción al alcohol. Para ubicar las fuentes se realizó una búsqueda en las bases de datos Ovid, Medline, Cinalh, Psych Info, Lilacs y Scielo, que comprendió el periodo 1988 a 2008, y en el que se ubicaron once artículos mediante las palabras clave: abuso de alcohol, adicción, dependencia, recuperación, experiencia e investigación cualitativa; de estos únicamente seis cumplieron con los criterios de calidad para ser incluidos en la metasíntesis. Los hallazgos permiten señalar que la recuperación es concebida como una trasformación con movimiento ascendente, conceptualización que implica reconocer la potencialidad de los aspectos positivos de las personas, alcanzar la madurez psicológica y espiritual, y lograr la paz y la libertad para actuar. En conclusión, este proceso de transformación inmerso en la recuperación debe ser reconocido por el profesional de enfermería para establecer, entre ese otro y ella, una fructífera interacción que permita el desarrollo del cuidado.

A meta-synthesis is presented to determine the features of the recovery process in persons who are addicted to alcohol. The metasynthesis method is founded on the integration and interpretation of findings from certain qualitative studies that shed light on substantial elements in the creation of new interpretations of the phenomenon of recovery from alcoholism. A search of the Ovid, Medline, Cinalh, PsychInfo, Lilacs and Scielo databases, covering the period from 1988 to 2008, was conducted to locate these sources and eleven (11) articles were found using the key words: alcohol abuse, addiction, dependency, recovery, experience and qualitative research. Only six of these words met the quality criteria to be included in the meta-synthesis. The findings indicate recovery is perceived as a transformation with an upward movement, a notion that implies recognizing the potential of a person's positive aspects, achieving psychological and spiritual maturity, and acquiring the peace and freedom to act. In conclusion, nursing professionals must recognize this process of transformation immersed in the recovery process, so as to establish fruitful interaction between themselves and the other person that allows care to develop.

Este artigo apresenta metassíntese, cujo objetivo é estabelecer as características do processo de recuperação nas pessoas que são viciadas no álcool. A metodologia metassintética se fundamenta na integração e interpretação dos descobrimentos de alguns estudos qualitativos que permitem reconhecer elementos substanciais na criação de novas interpretações no fenômeno de recuperação do vício no álcool. Para localizar as fontes, realizou-se uma busca nas bases de dados Ovid, Medline, Cinalh, Psych Info, Lilacs e SciELO, que compreendeu o período de 1988 a 2008, na qual se localizaram onze artigos a partir das palavras-chave: abuso de álcool, vício, dependência, recuperação, experiência e pesquisa qualitativa; destes onze, unicamente seis cumpriam os critérios de qualidade para serem incluídos na metassíntese. Os descobrimentos indicam que a recuperação é concebida como uma transformação com movimento ascendente, conceptualização que implica reconhecer a potencialidade dos aspectos positivos das pessoas, atingir a maturidade psicológica e espiritual, bem como a paz e a liberdade para agir. Em conclusão, esse processo de transformação imerso na recuperação deve ser reconhecido pelo profissional de enfermagem para estabelecer, entre este outro e ela, uma frutífera interação que permita o desenvolvimento do cuidado.

Uso potencial dos anticonvulsivantes no tratamento ambulatorial da dependência de álcool / Potential use of the anticonvulsants in the outpatient treatment of alcohol dependence

Atualmente três medicações (dissulfiram, naltrexona e acamprosato) são aprovadas pela Food and Drug Administration (FDA) para tratar a dependência de álcool. As drogas anticonvulsivantes clássicas são raramente empregadas como alternativa por causa dos seus efeitos colaterais, mas a sua última geração pode ser útil. Os anticonvulsivantes podem ser uma alternativa aos benzodiazepínicos (BZD) e a outros tratamentos farmacológicos na prevenção de complicações na desintoxicação por apresentarem ausência de propriedades aditivas e um melhor perfil de efeitos adversos do que os anticonvulsivantes clássicos. Anticonvulsivantes como carbamazepina, ácido valpróico, gabapentina e topiramato demonstraram-se excelentes tratamentos para síndrome de abstinência do álcool e prevenção de recaídas. Embora nenhum desses agentes tenha sido aprovado pela FDA, existe uma crescente evidência na literatura que apóia o seu uso.

Currently three medications (disulfiram, naltrexone and acamprosate) are approved by the FDA to treat alcohol dependence by the FDA. The classical anticonvulsive drugs are rarely employed as an alternative because of their side effects, but the latest generation of anticonvulsants could be useful. The anticonvulsants can be a alternative to BZD and other pharmacological treatments in the prevention of complications during the detoxification therapy, because of the absence of addictive properties and a better adverse effects profile than classical anticonvulsant drugs. Anticonvulsants such as carbamazepine, valproic acid, gabapentin and topiramate have shown to be excellent treatment for alcohol withdrawal and for the prevention of alcohol relapse. Although none of these agents have been approved by the FDA yet, there is growing evidence in the literature to support their use.

Aspectos neurofarmacológicos do uso crônico e da Síndrome de Abstinência do Alcool / Neuropharmacological aspects of chronic alcohol use and withdrawal syndrome

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.

Complicacões psiquiátricas do uso crônico do álcool: síndrome de abstinência e outras doencas psiquiátricas / Psychiatric complications of alcoholism: alcohol withdrawal syndrome and other psychiatric disorders

A síndrome de abstinência alcoólica é um quadro agudo, caracterizado por um conjunto de sinais e sintomas autolimitados, com gravidade variada, secundário à interrupcão total ou parcial do consumo de álcool, podendo ser associado a inúmeros problemas clínicos e/ou outros transtornos psiquiátricos. O objetivo deste artigo é rever as principais complicacões psiquiátricas secundárias à síndrome de abstinência alcoólica, como convulsões e delirium tremens, bem como algumas outras condicões psiquiátricas associadas à dependência de álcool, como as síndromes de Wernicke Korsakoff e de Marchiava Bignami. Pretende-se, com isso, auxiliar no diagnóstico precoce e tratamento adequado, minimizando assim a morbidade e a mortalidade associadas a tais complicacões.

[Neuropharmacological aspects of chronic alcohol use and withdrawal syndrome]. / Aspectos neurofarmacológicos do uso crônico e da síndrome de abstinência do alcool.

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.

[Psychiatric complications of alcoholism: alcohol withdrawal syndrome and other psychiatric disorders]. / Complicações psiquiátricas do uso crônico do álcool: síndrome de abstinência e outras doenças psiquiátricas.

Alcohol withdrawal syndrome is an acute condition secondary to total or partial reduction of alcohol consumption, characterized by self limited signs and symptoms and different degrees of severity. It can be complicated by several clinical and/or other psychiatric related problems. The objective of this article is to review the most important psychiatric complications to alcohol withdrawal syndrome as well as other psychiatric disorders associated with alcohol dependence as Wernicke Korsakoff and Marchiava Bignami syndromes. We aim to promote early diagnosis and treatment of these conditions, minimizing morbidity and mortality associated with them.

La mujer y el alcoholismo en México en el siglo XIX / Woman and alcoholism in Mexico in the XIX century

La condición social y las costumbres de la mujer mexicana del Siglo XIX, provocaban que ciertos padecimientos en que se veía involucrada la moral y la intimidad fueran sólo estudiados en los estadios avanzados; este es el caso de la sífilis y el alcoholismo. Durante ese siglo fue patente la difusión de conductas ejemplares y normas de vida que rechazan los excesos. La mujer reflejo de la educación impartida en el hogar o en sitios especializados, como el Colegio de las Vizcaínas. Se pensaba que la mujer tenía una naturaleza frágil y sensible que la hacía propensa a emociones y a sentimientos nobles. Se tenía la convicción de ciertos padecimientos eran producto del mal funcionamiento de su útero, su deseo sexual y su idiosincrasia; así catalogaron la histeria y la clorosis como enfermedades de la mujer. Cuando a principios del siglo XIX, Esquirol describió el delirio de los bebedores, nació una nueva entidad que se llamó alcoholismo. Rápidamente surgieron estadísticas a nivel mundial y nacional de individuos afectados por el alcoholismo. Las profesiones de riesgo relacionadas con el consumo de alcohol eran las de minero, licorista, vinatero y cochero. En la clase obrera, como política, se les invitaba a beber por la mañana. Los protocolos notariales de la época muestran que mujeres ejercían también este tipo de trabajo. El alcoholismo era más frecuente en mujeres de clase media, contrariadas y sujetas a un continuo sufrimiento por reyertas matrimoniales. Se decía que las mujeres se emborrachaban más fácilmente. Las manifestaciones de alcoholismo crónico en las mujeres están documentadas en periodo hiperestésico. Aquí se incluía la histeria alcohólica, la epilepsia alcohólica, el delirium tremens, la lipemanía y la dipsomanía. Como resultado final, en este periodo se podía observar la pérdida de las facultades mentales y afectivas. En la epilepsia alcohólica, las convulsiones eran de una sensibilidad más exquisita que en el hombre. La histeria alcohólica demostraba la relación que había entre los nervios del útero y del cerebelo. En mujeres con delirium tremens, en las que había una pasión dominante, como celos, los expresaban en cada acceso delirante. La dipsomanía se presentaba en mujeres menopaúsicas. Es evidente la represión social las obligaba a emborracharse en forma oculta. Cuando el alcoholismo se convertía un problema psiquiátrico se reducía a su forma histérica y epiléptica, finalmente son expresiones femeninas de patología mental de la época