CIWA-Ar for Alcohol Withdrawal

Why Use

The CIWA-Ar provides an efficient (<5 mins) and objective means of assessing alcohol withdrawal that can then be utilized in treatment protocols. Patients frequently under-report alcohol use and physicians often overlook alcohol problems in patients ( Kitchens JM 1994 ). It is estimated that 1 of every 5 patients admitted to a hospital abuses alcohol (Schuckit 2001). Unrecognized alcohol withdrawal can lead to potentially life-threatening consequences including seizures and delirium tremens.

When to Use

Patients in a variety of settings, including outpatient, emergency, psychiatric, and general medical-surgical units, for whom there is clinical concern for alcohol withdrawal.

Formula

Pearls / Pitfalls

The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scale has ten items, each evaluated independently then aggregated to yield a score correlating with severity of alcohol withdrawal. There is no absolute relationship between alcohol use pattern and risk of physiologic dependence or withdrawal for a given individual. In general, any suspicion of daily alcohol use over several weeks or more, regardless of quantity, should raise concern for potential alcohol withdrawal. Cannot be used effectively in intubated/sedated patients. A sedation scale such as the Richmond Agitation-Sedation Scale (RASS) is more appropriate in this setting. Additional variables that may contribute to risk include age, medical comorbidities like hepatic dysfunction, concomitant medication use, and low seizure threshold ( Roffman JL 2006 ).

Management

Assessment protocols utilizing CIWA-Ar vary and include medication dosing triggered by symptoms only and combined symptom-triggered + fixed-dose medication dosing.

Critical Actions

Other conditions can mimic or coexist with alcohol withdrawal, including: Drug overdose. Trauma (eg, intracranial hemorrhage). Infection (eg, meningitis). Metabolic derangements. Hepatic failure. Gastrointestinal bleeding. Consider additional testing to rule out alternative diagnoses, especially if presentation includes altered mental status and/or fever.

Advice

Benzodiazepines are generally used to control psychomotor agitation and prevent progression to more severe withdrawal. DiazePAM (Valium), LORazepam (Ativan), and chlordiazePOXIDE (Librium) are the most frequently used benzodiazepines. Follow your hospital’s own alcohol withdrawal protocol; frequently treatment begins with benzodiazepines when CIWA-Ar scores reach 8-10, with standing or as needed dosing for scores 10-20. Some protocols even include transfer to the ICU for scores >20. Consider additional supportive care, including intravenous fluids, nutritional supplementation, and frequent clinical reassessment including vital signs.

More Information

Score Withdrawal Level ≤8 Absent or minimal withdrawal 9-19 Mild to moderate withdrawal ≥20 Severe withdrawal