MANAGEMENT OF ALCOHOLIC PATIENT WITH CONFUSION AND CHRONIC MANIFESTATIONS:
If patient has an history of Chronic alcohol intake or malnourishment and is hypoglycemic , patient should be given iv Thiamine before glucose to prevent development of Wernicke”s Encephalopathy.
This is achieved by giving two pairs of ampoules of high potency Thiamine ( Pabrinex) intravenously.
Specific management depends upon the cause and diagnosis.
If patient has Acute on Chronic liver failure related to alcohol , note the following :
Hypovolemia and electrolyte disturbance :
Hypoglycemia :
Give intravenous glucose to maintain finger prick glucose more than 3.5 mmol/l
Patient may need continuous infusion of 10 % dextrose but only after administration of thiamine.
Hypovolemia :
Give colloid rather than the 0.9 % normal saline
Hypokalemia
Give intravenous potassium can be added 20 mmol ampoule in colloid.
Hyponatremia :
This is common and occur due to water excess and not sodium deficiency , hence should be treated with water restriction and not 0.9 % saline.
Hypophosphatemia :
Start intravenous or oral phosphate replacement therapy.
Feeding and Gastric protection :
Nasogastric tube : Adequate nutrition is important
Medications can be administered by this route
Ranitidine 50 mg iv tds to reduce risk of stress ulcers.
Reduction of Intestinal nitrogenous load:
Start lactulose 20 – 30 ml or lactilol 10 g tds reducing the dose when diarrhea starts.
Phosphate enema should be administered.
Neomycin or metronidazole should be given if patient is poorly responsive or comatose.
Coagulopathy :
Vitamin K should be given orally or intravenously .
In case of active bleeding , patient may be given Fresh frozen plasma or platelets.
Underlying Infections :
A broad spectrum antibiotic maybe given in case of suspected sepsis / infection of unknown origin.
This includes : Intravenous Ceftriaxone 2 Gm iv OD or Cefotaxime iv 2 Gm OD.
Bacterial peritonitis may occur in 25 % patients with Cirrhotic ascites.
Vitamin Supplementation:
Vitamin B and C are usually given in chronic alcoholics.
In case of impaired consciousness , give in Pabrinex / Thiamine 2 – 3 pairs of ampoules 8 hourly.
If patient can take orally , oral thiamine 50 mg once a day and vitamin B compound tablets strong ( 1-2 tablets tds ) and vitamin C once a day may be given.
Anticipate and Treat Complications :
The development of complications indicates a very poor prognosis.
This issue needs discussion with senior colleagues depending on the individual case as escalation of treatment may be inappropriate and futile.
Hepatorenal failure
Renal failure is a common complication of hepatic failure in Alcoholic patients.
It usually occurs secondary to Acute Tubular Necrosis.
Prognosis of hepatorenal failure is very poor.
Cerebral oedema is another sinister complication .
Mannitol can be given 200 mg/kg iv slowly.
Intracranial pressure monitoring maybe useful but not available in all centres.
Alcohol withdrawal and delirium tremens
Acute alcohol withdrawal is common.
It usually causes tremors and confusion after 8 – 24 hours and settles after 48 hours.
Delirium tremens:
This is are but can be fatal if untreated.
It causes termors,confsuin, visual hallucinations , fever and sweating.
It usually occurs afer 3 -4 days of stopping drinking.
Aside from supportive measures, give vitamins , treat hypoglycemia and prescribe sedation.
If patient can tolerate oral therapy , give chlordiazepoxide 30 mg four times a day on day 1 then treat with lowering doses.
If patient is severely agitated and cannot tolerate oral medications , give intravenous chlormethiazole 0.8 % solution at rate of 20 – 60 mg / min until a shallow sleep from which patient can be easily aroused is induced.
Then reduce rate to lowest possible to maintain shallow sleep and normal spontaneous respiration.
Chlormethiazole can cause respiratory depression so sgould be administered carefully.
Patient should be closely monitored and full resuscitation facilities should be made available.
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