Association with somatic pathologies
Withdrawal treatment and its integration into an overall long-term care strategy are integral to the treatment of the person with somatic alcohol-related complications. We must not forget about the placement in the alcohol-dependent patient. The encephalopathy of Gayet Wernicke must be prevented by the supply of vitamin B1. If present, it is a metabolic emergency to treat intravenously 1 g of thiamine per day. Severe hyponatremia is a risk factor for centropontinine myelinolysis and needs to be corrected progressively. Withdrawal favors the accumulation of drugs (regression of enzymatic induction linked to alcoholization). Dosage adjustments should be considered in case of withdrawal. In the case of hepatocellular insufficiency or cirrhosis, the possible alcohol rehab prescription of BZD should be very cautious (risk of accumulation and increased brain sensitivity to BZD). In a surgical setting, non-recognition of alcohol dependence can lead to increased severity of weaning and more frequent postoperative infections. Alcohol dependence must be sought preoperatively in the surgical environment or during each emergency hospitalization, as well as precursors of postoperative weaning neurological symptoms.
Treatment of weaning accidents [ 1 ] [ 7 ] [ 10 ] [ 16 ]
Weaning accidents are represented by delirium tremens (DT) and seizures. In general, they occur during an imposed withdrawal or result from an error in the conduct of programmed weaning. They justify, according to the degree of seriousness, hospitalization in an intensive care unit or in conventional medical unit.
Psychotropic treatment is based on the intravenous use of BZD. Diazepam and flunitrazepam have been validated in this indication [ 23 ] . The alcohol rehab often proposed has not yet been validated. The risk of respiratory depression requires hospitalization in a structure with resuscitation. The hydro electrolytic rebalancing is essential as well as the addition of thiamine (500 mg to 1 g / day). Clonidine may be of interest in cases of major hypertensive crisis. Corticosteroids have been proposed [ 24 ] but are not validated. The treatment of favoring factors (infection …) should be considered systematically
Convulsive crisis [ 16 ] [ 25 ]
In the event of a generalized seizure, the other etiologies, frequent in alcoholic disease: hypoglycemia, hyponatremia, head trauma, cerebral-meningeal infection, cerebrovascular accident, drug poisoning, alcoholic epilepsy (not related to weaning) must be sought immediately. , evoking toxicity of alcohol on neurons).
Convulsions of weaning occur in 90% of cases in the first 48 hours and are of the type of severe pain in 95% of cases. In the majority of cases, the electroencephalogram is normal. They are observed in 5 to 30% of withdrawal syndromes [ 25 ] [ 26 ] [ 27 ]. The risk factors statistically found are the use of psychotropic drugs, a history of withdrawal convulsions, a history of traumatic brain injury. Taking drugs that lower the seizure threshold is also a risk factor. In cases of seizure reproduction, intravenous treatment with diazepam or clonazepam is warranted if respiratory resuscitation is available (the intramuscular route is not recommended).
Convulsions independent of weaning, to be systematically sought, are the subject of a specific treatment. A convulsive single withdrawal seizure does not warrant antioxidant treatment. In case of failure, the treatment can be renewed according to the recommendations of the corresponding Consensus Conference [ 28 ] .