Abstract
Introduction: Data suggest that phenobarbital is as effective as benzodiazepines at managing withdrawal via its direct activation of the gamma-aminobutyric acid receptor and modulating glutamate-mediated stimulation of the N-methyl-D-aspartate receptor. There are little data evaluating the effect of phenobarbital on severe withdrawal syndromes. Objective: The purpose of this study was to evaluate the effect of phenobarbital compared with protocolized, symptom-driven, benzodiazepine administration on hospital length of stay (LOS) in patients experiencing severe withdrawal. Methods: This is a retrospective chart review of patients evaluated in the emergency department for the treatment of severe alcohol withdrawal syndrome, defined as a Clinical Institute Withdrawal Assessment for Alcohol – Revised score of 20 or greater during their visit. The primary outcome measure was the difference in hospital LOS between those receiving phenobarbital and those receiving continuous lorazepam infusions. Secondary outcomes include intensive care unit (ICU) admission, ICU LOS, need for mechanical ventilation, and incidence of oversedation. Results: In all, 298 patients met inclusion, with 131 treated with phenobarbital and 167 initiated on a lorazepam infusion. Hospital LOS was found to be statistically significantly greater in the lorazepam infusion cohort (7.6 ± 5.3 vs. 5.2 ± 4.5 days, P < 0.001) than the phenobarbital cohort. Patients treated with lorazepam were found to have increased admissions to the ICU (risk ratio [RR] 1.79 [95% CI 1.27–2.92]) and higher rates of oversedation (RR 1.71 [95% CI 2.09–4.25]). There were no differences in ICU LOS and need for mechanical ventilation. Conclusion: Data from this study suggest that phenobarbital may be associated with a decrease in hospital LOS in severe alcohol withdrawal and should be considered as an alternative to benzodiazepine infusions in these patients.