Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: Severe alcohol withdrawal is highly morbid, costly and common among patients admitted to the intensive care unit.
Speaker: Unfortunately, a positive of high level evidence and commonly held misconceptions are often associated with suboptimal clinical management.
Speaker: In today's episode of the podcast, we will discuss the ICU management of severe alcohol withdrawal.
Speaker: Our guest is Dr. Nick Mark, a critical care physician practicing in Seattle, Washington.
Speaker: Dr. Mark is passionate about open access medical education and medical technology.
Speaker: He's the founder and creator of OnePagerICU, a wonderful resource that provides regularly updated, comprehensive, and practical one-page summaries on various critical care topics.
Speaker: Dr. Mark is also a consultant for critical care-related technology.
Speaker: You can find him at OnePagerICU.com and on Twitter at Nick M. Mark.
Speaker: Nick, welcome to the podcast.
Speaker: Thanks for having me.
Speaker: It's great to be here.
Speaker: Well, before we dive into the topic, I guess the world of critical care is a small one, and
Speaker: We certainly have a lot of friends in common, it seems.
Speaker: However, this particular episode of the podcast came through by me following your wonderful One Pager.
Speaker: So before we dive into alcohol withdrawal, could you tell us a little bit more about OnePagerICU.com?
Speaker: Sure.
Speaker: So the website started about two years ago at the beginning of COVID.
Speaker: Being in Seattle, I was on the front lines of seeing the first cases in the U.S. And my learning style has always been to write stuff down, try to simplify it.
Speaker: And so as I was learning about COVID, as we all were, I took notes on a piece of paper and then I thought, oh, I'll just share this with people.
Speaker: So I took a screenshot, I took a photo of it, tweeted it, went to sleep because it was at the end of a long night shift, woke up in the morning and that tweet had gone viral.
Speaker: And lots of people were interested in this one pager about COVID.
Speaker: So then I thought, okay, well, maybe this is valuable to people.
Speaker: So I kept updating that.
Speaker: And then I realized that, well, wait a second, there's a whole world of critical care beyond just COVID.
Speaker: So maybe I should make one pagers on other topics.
Speaker: And the website was just sort of an outgrowth of that.
Speaker: You know, I shared them on Twitter and social media, and it was kind of painful to just be emailing people PDFs.
Speaker: I thought, I'll just make a website to make it easier to share.
Speaker: And so the site has grown organically from there over the last two years.
Speaker: I think I've got about 51 pagers now.
Speaker: You know, long term, I may turn them into a book, though I kind of like the idea that they're all open access.
Speaker: You can download them, you can edit them, you can make them your own.
Speaker: The only requirement is, is that if you download them and edit them, you have to make that freely available.
Speaker: So just keep that open access thread alive.
Speaker: Absolutely.
Speaker: And two points, I mean, to follow up from my own experience, on one hand, obviously the open nature, right, which in terms of what we're trying to do is share ideas and learn from these ideas.
Speaker: So like you said, as these things evolve, if they share them again, it continues to move forward, the quality.
Speaker: But also what I have found, and I'm sure that you have found the same thing, is that by creating content, ultimately you're probably the greatest beneficiary.
Speaker: I mean, I'm sure that those are 51
Speaker: topics that perhaps you wouldn't have read as in depth as you have over the last several years because of these one-pagers?
Speaker: Absolutely.
Speaker: I mean, the best way to learn is to teach.
Speaker: Later today, I'll probably publish this one that I've been working on for almost two years on enteral nutrition in the ICU, which is a topic that I did not know nearly as much about before I started on this as I do now.
Speaker: It's a great forcing function to learn about stuff.
Speaker: Sometimes I'll pick topics that are things that I don't feel knowledgeable about because I want to learn more about them.
Speaker: And I think that that's really a great message for all our listeners.
Speaker: I mean, by creating and sharing, you will learn a lot.
Speaker: And I have definitely found that with the podcast.
Speaker: And as you have shared with the one pagers, it's no different.
Speaker: So let's go ahead.
Speaker: That's great too, right?
Speaker: I mean, so if you write an article, you'll have two or three peer reviewers who will critique it.
Speaker: If you share something that's downloaded thousands or tens of thousands of times, you get a lot more feedback than that.
Speaker: And sometimes that feedback is not always the most positive, but it can be very helpful.
Speaker: I remember one one-pager I did talking about how to prevent volume overload in the ICU.
Speaker: And oh man, those nephrologists give some good feedback.
Speaker: I think I'm on version 11 or 12 of it right now because I got so much feedback over like the month or two after I released it.
Speaker: Excellent.
Speaker: But like you said, if the goal is to learn and share and share knowledge, that feedback is so important and something that we seldom get, like you said, even if you submitted a paper, but even when we give presentations, right, we don't really get feedback at all.
Speaker: It's just maybe a couple of questions and then it's gone.
Speaker: And the other thing that we discussed earlier was just the reach, right?
Speaker: How the world has changed with one pagers.
Speaker: I mean, how many people you are engaging with in one way or the other compared to spending an hour at a grand rounds.
Speaker: Absolutely.
Speaker: So let's dive into alcohol withdrawal.
Speaker: And perhaps we can just start with a little bit of a general background in epidemiology, the alcohol withdrawal syndrome.
Speaker: So I think to give some context, alcohol is the leading drug of abuse in the world.
Speaker: It is by far the most costly in terms of how many people die as a result of alcohol and how much money we spend treating the consequences of alcohol abuse.
Speaker: The number of people who are at risk for alcohol withdrawal is simply massive.
Speaker: So heavy drinking is defined as men who drink 15 or more drinks per week or women who drink eight or more drinks per week.
Speaker: And by that definition, 5% of Americans, about 16 million people are heavy drinkers.
Speaker: Half of those people will suffer withdrawal if they suddenly stop drinking.
Speaker: That means that roughly one person in 40 in the entire U.S. is at risk for withdrawal.
Speaker: But the numbers in the hospital are even higher because of course alcohol is a reason that people come into the hospital.
Speaker: It's estimated that 40% of people in the hospital have alcohol use disorder and are at risk for withdrawal.
Speaker: And depending on why you came into the hospital, it could be even higher than that.
Speaker: Something like 50% of trauma patients are intoxicated and 15 to 30% of them will have withdrawal while they're in the hospital.
Speaker: So alcohol withdrawal is incredibly common.
Speaker: And yet, despite that, it's an easy diagnosis to miss if you don't consider it.
Speaker: So I think great general framing on this problem is you should consider alcohol withdrawal in every patient in the hospital and convince yourself why you don't have to worry about it as opposed to the other way around.
Speaker: I think that's a great point.
Speaker: And I also think that that it just speaks to what we were talking before we started recording that
Speaker: drugs of abuse and medical problems related to abuse of any substance seems to have increased over the last several months with COVID.
Speaker: And I don't have any data.
Speaker: I don't know if you have that you can share, but clearly my clinical observation is that I've had a lot more alcohol withdrawal, it seems, lately during the last 24 months than I've seen before COVID.
Speaker: Yeah, I don't have any clinical data on that either, but my anecdotal experience is the same as yours.
Speaker: And as we know, the plural of anecdote is evidence, right?
Speaker: So I think there is something there.
Speaker: I think we've definitely seen a change in the way people drink, the quantity people drink, and the frequency with which people drink alcohol during the pandemic.
Speaker: And I think we're seeing that both in terms of more alcohol withdrawal and in terms of more adverse effects of alcohol, like more liver disease.
Speaker: I wonder if there'll be studies in the next year or two that will back that observation of ours up.
Speaker: Can you tell us a little bit
Speaker: about the pathophysiology, just, I mean, one-on-one, so people can, I think, frame this appropriately and understand as we talk about treatment.
Speaker: Yeah, so as a quick side note, alcohol is a really funny drug because it may be responsible for more deaths than any other drug, but in another sense, it's one of the least toxic chemicals you can ingest.
Speaker: You know, one drink of alcohol is more than 10 grams of ethanol.
Speaker: Imagine having 10 grams of Tylenol
Speaker: 10 grams of salicylate.
Speaker: 10 grams of almost anything would be fatal, but alcohol is relatively not potent.
Speaker: It also hits many different receptors in the brain, and that's why it has so many different effects.
Speaker: So ethanol binds to and triggers opioid receptors.
Speaker: That's why it can cause analgesia, it can cause nausea, it can cause respiratory depression.
Speaker: It can trigger cannabinoid receptors, causing hunger, hallucinations.
Speaker: But then most importantly, it stimulates GABA receptors.
Speaker: GABA receptors are the major inhibitory neurons of the central nervous system.
Speaker: And when alcohol triggers GABA, it causes inhibition and sedation is the clinical effect.
Speaker: Now, normally neurons need a balance between excitation and inhibition in order to function properly.
Speaker: If you chronically consume alcohol, there's very high level GABA signaling at all times, which inhibits neurons from firing.
Speaker: So in order to compensate, neurons upregulate the excitatory pathways and they downregulate GABA, so they restore that balance.
Speaker: But the problem is that when a person suddenly stops drinking and all that GABA inhibition is removed, the scale suddenly tips towards way too much excitation.
Speaker: And too much neuronal excitation can lead to seizures.
Speaker: It can lead to death of neurons from something called excitotoxicity.
Speaker: And this excessive excitation of neurons is what causes alcohol withdrawal.
Speaker: Now, I love analogies.
Speaker: So as an analogy for this, imagine a terrible driver who always drives with one foot on the brake and one foot on the gas.
Speaker: The brake is GABA, the accelerator is an MDA.
Speaker: Because of their heavy foot on the brake, they have to push the accelerator harder just to drive.
Speaker: Now imagine if you suddenly pull their foot off the brake pedal.
Speaker: The car is going to surge forward out of control.
Speaker: That's essentially what happens when people who are habituated to alcohol suddenly stop drinking.
Speaker: I think that an important point that sometimes people misunderstand is that
Speaker: It's not only that you have been not drinking any alcohol for some time, it's a decrease in your amount of intake for chronic users.
Speaker: So you can have people who come in with alcohol levels that are elevated, but if that's a big delta for them, that can be enough to kind of, like you said, stop the brakes, get the foot off the brake and really started the exciting pathway.
Speaker: Absolutely, and one of the biggest predictors of severe withdrawal is somebody who is withdrawing with a detectable blood alcohol level.
Speaker: So the fact that somebody's got alcohol detectable in the blood is not a good sign.
Speaker: If they're experiencing withdrawal symptoms, that's actually a bad sign.
Speaker: It predicts that they're more likely to have more severe withdrawal.
Speaker: Can we talk about the clinical manifestations?
Speaker: And you had a very nice...
Speaker: visual in your one page, you're kind of looking at this by timeframe horizontally, but also I think it's important to distinguish that there are really distinct clinical manifestations that might have different implications for where a patient's treated or what their risk is.
Speaker: And I think that sometimes people kind of muddle them and think it's all one, but really they're kind of distinct clinical presentations.
Speaker: Absolutely.
Speaker: And I think that's one of the most important takeaways of understanding alcohol withdrawal syndrome.
Speaker: Namely, that it's not really one clinical entity, but four overlapping ones.
Speaker: So you can think about them in terms of there's two that are more severe, which are delirium tremens and seizures, or you can think about them as sort of a time course that evolves over time.
Speaker: Running through them in time order, so minor withdrawal symptoms tend to occur earlier.
Speaker: This can happen as little as six to 12 hours after the last drink.
Speaker: These include symptoms like people who are headachy, anxious, tremulous, they feel nauseous.
Speaker: The key thing, though, is their vital signs are normal and their mentation is normal.
Speaker: They know where they are and who they are.
Speaker: The next thing that can happen, and this also happens early, like within hours, is withdrawal seizures.
Speaker: These are generally one or a few generalized seizures.
Speaker: Occasionally, they can be other types of seizures, and occasionally, they can develop into status.
Speaker: The key here is that somebody who stops drinking can have a seizure, and this can be a life-threatening consequence of alcohol withdrawal.
Speaker: The third clinical entity is alcoholic hallucinosis.
Speaker: And this is where people have hallucinations.
Speaker: This is the classic seeing pink elephants.
Speaker: These can be visual, auditory, or tactile.
Speaker: The key, though, is that people with alcoholic hallucinosis have intact orientation,
Speaker: They know where they are, they know who they are, but they're seeing stuff added into that, and that they have normal vital signs.
Speaker: This is in contrast to delirium tremens.
Speaker: Delirium tremens is a life-threatening manifestation of alcohol withdrawal, where people are delirious, they don't know where they are, they're agitated, often dangerously so, and they have autonomic instability, like tachycardia, fever, hypertension, diaphoresis.
Speaker: Now, of these four clinical entities, we should treat all of them, but the two that are really important to elicit when you're getting a history on somebody is, have you ever had a seizure before?
Speaker: Because that can be life-threatening.
Speaker: And have you ever had delirium tremens or DTs before?
Speaker: Because that's also the most life-threatening manifestation of AWS.
Speaker: And certainly, these are probably the most common reason why patients with alcohol withdrawal would come to an ICU.
Speaker: Absolutely.
Speaker: And it's important to remember that we see alcohol withdrawal in the ICU in two very different ways.
Speaker: We see alcohol withdrawal as the reason people are in the ICU.
Speaker: And we also see alcohol withdrawal complicating something else.
Speaker: Somebody gets admitted to the hospital for any number of things and then they develop alcohol withdrawal.
Speaker: And so you have to think about it in both contexts.
Speaker: Somebody who's newly admitted to the hospital where they have a label AWS
Speaker: and somebody who may be transferred from another part of the hospital because they're, quote, confused or because their vital signs are abnormal.
Speaker: And you also need to think about AWS in that setting.
Speaker: As you were starting, you had mentioned that obviously the importance of being very suspicious about potential alcohol withdrawal in terms of diagnosis is critical for us just because of the prevalence of alcohol-associated disease and the risk for alcohol withdrawal in patients that are hospitalized.
Speaker: Can we talk a little bit about a diagnosis and how do we make a diagnosis of severe alcohol withdrawal first?
Speaker: So unfortunately, this is a clinical diagnosis, meaning there is no lab test or imaging test that we can order that tells you this person has alcohol withdrawal.
Speaker: In order to have alcohol withdrawal, or basically alcohol withdrawal is defined as symptoms when you stop drinking alcohol in somebody who previously drank to excess.
Speaker: We make this diagnosis by saying this constellation of symptoms fits, the timing fits, and it doesn't seem like something else.
Speaker: So if one side of the coin is you always need to consider alcohol withdrawal because it's so common, and if you miss it, it can be serious,
Speaker: The other side of that coin is you should avoid falling into the trap of saying, quote, this is just alcohol withdrawal.
Speaker: You have to remember that people who are at risk for alcohol withdrawal are at risk for lots of other conditions that can mimic withdrawal.
Speaker: People who drink alcohol can have gastritis, pancreatitis, hepatitis.
Speaker: They're at high risk of pneumonia.
Speaker: And common conditions like sepsis and delirium can mimic AWS.
Speaker: Also, rarer things like meningitis or CNS bleeds or other intoxications can also mimic AWS.
Speaker: So while you need to maintain a high index of suspicion and convince yourself why this person doesn't have AWS, well, you don't have to worry about it, you also need to remember that somebody who has AWS could have something else or that they might have something else that's mimicking AWS.
Speaker: So the challenge is that any clinical diagnosis exists here.
Speaker: And I think it's worth digging a little bit deeper in the differential diagnosis because there are clearly a subset of pathologies that can present, like you said, with similar presentations as what you might be considering alcohol withdrawal syndrome, but the treatment might be very different.
Speaker: And in fact, if we were to treat it as alcohol withdrawal and we were wrong, we could actually harm our patients.
Speaker: Could you dive a little bit more into some of those specific differential diagnosis that we should consider in this situation?
Speaker: Yeah, so a couple that I listed here on the one page are hypoglycemia.
Speaker: So when you consume alcohol, it consumes NADH in your liver, and that can actually make it hard for you to break down glycogen and make more glucose.
Speaker: So people who drink alcohol are at risk for hypoglycemia.
Speaker: So you should always exclude that.
Speaker: It's quick.
Speaker: It's just one finger stick, and you know the answer in seconds.
Speaker: But you should always cross that off the list.
Speaker: You can also see other toxicities like serotonin syndrome, where you can have agitation, high body temperature, tachycardia.
Speaker: It can mimic a lot of the autonomic features of DTs.
Speaker: Similarly, hyperthyroidism or thyrotoxicosis can do the same.
Speaker: And then finally, remember that
Speaker: a lot of people who come into the hospital because of alcohol come in because of trauma.
Speaker: And that may be the reason they came in.
Speaker: They may have been in a car crash, or it may not be obvious.
Speaker: People who are intoxicated often fall down, and that may not be their presenting complaint.
Speaker: But head injury, in particular, bleeds into the brain can cause altered mental status and confusion that can mimic AWS.
Speaker: And then also remember that liver disease, which often results as a consequence of consuming alcohol chronically, can cause a patic encephalopathy.
Speaker: And that's a really important differential to consider because it's gonna have implications when you go to treat alcohol withdrawal.
Speaker: If you think this person might also have a patic encephalopathy, you're gonna have to be really careful about what medications you use and how you dose them.
Speaker: Excellent.
Speaker: Can you tell us, Nick, how would you recommend like an initial workup for these patients?
Speaker: Like you said, it's a clinical diagnosis, but obviously as you're trying to differentiate and just trying to figure out where a patient needs to go in the ED, from the ED, there are probably an initial workup that might be agreed upon.
Speaker: What would you recommend?
Speaker: So I think just having a broad, casting a broad diagnostic net is important.
Speaker: So sending sort of labs to look at
Speaker: kidney function, liver function, blood work to look for infection, considering things like thyroid, considering other toxins, like toxic alcohols in some cases, checking an alcohol level, because if the alcohol level is high, it can tell you something about the severity of their disease.
Speaker: I think certainly not everybody who comes into the hospital needs a CT scan of their head if they're confused.
Speaker: But I think this is a situation where if somebody's alcohol withdrawal is the reason that they're going to the ICU, you really want to make sure that they don't have another CNS pathology that you've missed.
Speaker: Especially because if you start treating them for alcohol withdrawal by giving them benzos or barbiturates, you're going to make the physical exam that much harder, which is going to be a key part of assessing any concomitant head injury.
Speaker: Excellent.
Speaker: And there's also a host of objective scoring frameworks that have been proposed, that have been studied to some extent, and that are commonly utilized or misutilized in clinical practice.
Speaker: Could you comment on some of the ones that you have found to have the most robust evidence or that you would recommend our clinicians being familiar with?
Speaker: Yeah, so I think the one that most people are probably familiar with is called CIWA, which stands for the Clinical Institute of Withdrawal Assessment Scale for Alcohol.
Speaker: So Clinical Institute of Withdrawal Assessment is CIWA.
Speaker: This is probably the most commonly used way of evaluating the severity of alcohol withdrawal.
Speaker: And you can use this one to trigger therapies, like say if their score is above X, they will receive a dose of benzodiazepine.
Speaker: But before you even get to using CWA, there's another score that you should consider using, which is called PAWS or P-A-W-S-S or prediction of alcohol withdrawal severity scale.
Speaker: This is a very sensitive and specific scale that you can use to evaluate if somebody is at risk for developing an AWS at all.
Speaker: So this is typically done in admission.
Speaker: It does require a lot of patient participation, which is a limitation of a lot of these tests, a lot of these scoring systems.
Speaker: But the advantage of PAUSE is that a low PAUSE score in a patient who's able to communicate really is very good at reassuring you their risk of alcohol withdrawal as well.
Speaker: And conversely, a high score, a score of four or greater, tells you they're at very high risk for withdrawal and might even prompt you to treat them differently.
Speaker: The last one, so PAUSE tells you, is this person at risk for withdrawal?
Speaker: CWA tells you,
Speaker: in this person who is experiencing withdrawal, how severe is it?
Speaker: AWS is derived from CIWA, the alcohol withdrawal score, and it tries to fix some of the limitations of CIWA.
Speaker: So probably the biggest limitation of CIWA is it requires the patient to participate.
Speaker: And there can be a lot of variation in how patients answer questions.
Speaker: If you ask somebody, are you feeling anxious?
Speaker: You know, that's not super objective.
Speaker: There's a large subjective component to that.
Speaker: And what AWS does is it adds in vital signs to try to make CIWA a little bit more objective.
Speaker: I think CIWA is still probably the one that's most widely used.
Speaker: It's the one that we tend to think about most often when we think about alcohol withdrawal.
Speaker: But I think increasingly people are looking to AWS as an alternative, especially in sicker patients who are not able to communicate as well.
Speaker: And often also in the ICU for the most severe cases,
Speaker: If the patient ends up intubated, none of these obviously are that helpful.
Speaker: And now what a lot of people recommend, I guess, is using other scales that are more commonly used in the ICU for non-alcohol withdrawal situations.
Speaker: Exactly.
Speaker: So let's dive into treatment.
Speaker: And before we go into the specific treatment options for the alcohol withdrawal symptoms themselves,
Speaker: I think it's probably worthwhile reminding our listeners, what are some basic nutrition and fluid tenants that we should get started as these patients are being moved from the ED to the ICU?
Speaker: Right, so I think it's important to remember that people who abuse alcohol are at risk for a lot of different electrolyte and fluid derangements.
Speaker: In many cases, they have vomiting, they're having high insensible losses,
Speaker: They can be dehydrated as a consequence of losing free water from alcohol.
Speaker: They can be hyponatremic for the same reason.
Speaker: And so correcting those deficits carefully is important.
Speaker: In many cases, people who chronically consume alcohol are deficient in thymine and folate, so we should just give those to people.
Speaker: Many hospitals have so-called banana bags, which are bags that have thymine and folate in them.
Speaker: adding B vitamins to liquid makes it kind of yellowish.
Speaker: That's why they look yellow and they call them a banana bag, by the way.
Speaker: I think one important thing to remember is that hypokalemia and hypomagnesemia are very common.
Speaker: And if you don't check a mag, you're gonna spend all day trying to fix that low potassium and it's not gonna stay up.
Speaker: So it's worthwhile to check magnesium in these patients, check phosphate, check potassium, and then make sure to correct all of those together.
Speaker: I'm not a fan of doing maintenance fluids in general.
Speaker: I think that we tend to give people more than we need to when we just write a standing order.
Speaker: But when I'm admitting somebody with alcohol withdrawal, I will often write them for a liter or two of fluid because at baseline, they are likely dehydrated and volume deplete.
Speaker: And obviously, you've mentioned with thiamine, the concern obviously for
Speaker: Wernicke's encephalopathy and what I understand there, Megan, if you can just correct me if I'm wrong, but first that it probably IB or IM is best in these patients for these replacements initially, just because of the potential for malabsorption, but also that early is probably better than delayed in terms of preventing things.
Speaker: And then finally, it,
Speaker: For many years, I've heard people talk about the order of replacement in people who are hypoglycemic, but it seems that the data doesn't really support that.
Speaker: And at the end of the day, what's important is to give the thiamine early and move on and not worry if you've given the dextrose or give the dextrose afterwards.
Speaker: Is that the correct interpretation?
Speaker: Yeah, I think that's right.
Speaker: This is one of those great examples of medical myth busting or medical lore that's not really based on a lot of fact.
Speaker: So I remember when I was an EMT, it was always a failure point.
Speaker: if you gave dextrose in the unconscious person in training without giving them thymine first.
Speaker: The thinking was that if you gave dextrose without first giving thymine, you could cause ornickies.
Speaker: I think that has not really been borne out in later studies.
Speaker: It probably doesn't matter the precise order.
Speaker: As you said, I think it's much more important to cover your bases, treat people for potential vitamin deficiencies early.
Speaker: It's also worth noting that if you think that somebody has Wernicke's, which is a whole separate conversation, the dose of 100 milligrams of thymine is inadequate.
Speaker: You need to use a much higher dose, like 500 milligrams three times a day for several days.
Speaker: So don't think that you, by giving 100 milligrams of thymine, you cross Wernicke's off the list.
Speaker: You should think about Wernicke's if they have ataxia and gaze abnormalities.
Speaker: Excellent point.
Speaker: I think it's important also to recognize that this could be an associated condition, not frequent, but if missed and not treated in a timely manner, obviously can have dire consequences for our patients.
Speaker: And just like alcohol withdrawal, a good example of a diagnosis that you'll never make if you don't look for it.
Speaker: Well said.
Speaker: So as we move on with the more specific treatment for the different clinical manifestations that you discussed earlier, and obviously we are most concerned in the ICU at least with withdrawal seizures and delirium tremens because of the high morbidity and potential mortality that they're associated with, one of the things that you often hear and read about in alcohol withdrawal treatment is different strategies, symptom-based versus a fixed dose versus front-loading,
Speaker: Could you just explain a little bit of what are those and what is kind of the general direction that the literature points us to?
Speaker: And then we can maybe dive into more specific therapeutic options.
Speaker: Yeah, so backing up just one step, remember that the goal of treatment is to treat symptoms and prevent life-threatening complications.
Speaker: There's many different ways to achieve this, and it really depends on a couple of factors.
Speaker: One is how severe is your patient's withdrawal symptoms?
Speaker: Milder symptoms can be treated differently than severe symptoms.
Speaker: And also, what is your institutional expertise and comfort with, right?
Speaker: There are many different choices of medications.
Speaker: And so this is a good example of where you really want to do this as a system, not as an individual.
Speaker: You want to use the medications that everybody in your group is comfortable with.
Speaker: That way, it's not, you know, oh, this doc always uses phenobarb.
Speaker: This guy always uses Ativan.
Speaker: You know, having more of a consensus is probably key too.
Speaker: That way everybody gets the same high level of care.
Speaker: There have been a couple of studies that have looked head to head at different approaches.
Speaker: And in general, they have not found that benzos or garbiturates, that one is superior to the other.
Speaker: I think there are advantages to both.
Speaker: And I'll tell you kind of how I approach this.
Speaker: First of all, for people with milder symptoms,
Speaker: symptom-driven benzodiazepines is probably the best approach.
Speaker: And the reason is that it avoids overdoing it.
Speaker: If the person is able to communicate and participate in a CWES score and you can treat their symptoms with doses of benzos to match their symptoms, this is a really good way to treat withdrawal without causing excess sedations.
Speaker: But if you do this, you have to be ready to escalate quickly if you're not meeting your goals.
Speaker: You can't have somebody hanging out with a CWA score of 30 for a couple of hours because they've maxed out.
Speaker: On the other hand,
Speaker: In people who are at high risk for severe withdrawal, such as people who have had DTs before, people who have been admitted to the ICU for withdrawal before, I prefer a more front-loaded phenobarb approach.
Speaker: So in this approach, you identify somebody who's at high risk, who has not yet received a lot of other meds, and you load them with 10 milligrams per kilogram of phenobarbital.
Speaker: You check a level, you re-dote if necessary.
Speaker: The advantage of this approach is
Speaker: you're not gonna underdo it this way.
Speaker: It avoids the risk of getting behind that sometimes happens with a symptom-driven approach.
Speaker: But you have to be careful about interactions with other medications.
Speaker: You have to be careful about hepatic encephalopathy.
Speaker: And you have to be mindful that some patients have already received some benzos by the time they come to the ICU.
Speaker: So in those patients, you have to be cautious about synergy and maybe instead of loading them with the full 10 milligram per kilogram dose, use a lower loading dose to do it safely.
Speaker: I think one... I think one key tenant of treating alcohol withdrawal is reassess frequently and escalate if you're not meeting your goals.
Speaker: And that's true whether you're using a benzo approach or a phenobarb approach.
Speaker: And that was going to be a question I have, Nick, specific, because I often get called from the ED or from a hospice who somebody was going to be admitted to another unit, and now they want to send to the ICU.
Speaker: But usually what I find is when I ask what the patient has received, it's not a lot.
Speaker: Right.
Speaker: And pharmacologically, there's a reason for using barbiturates in addition to benzos.
Speaker: So they both affect that GABA channel.
Speaker: Benzos make the GABA channel open more often, and barbiturates keep it open for longer.
Speaker: So giving both together can result in really nice synergy for treating that GABA deficiency, which is what causes alcohol withdrawal.
Speaker: So in that case, sometimes, like if somebody's on the floor, they've gotten a couple doses of lorazepam, they're still having symptoms.
Speaker: Sometimes in that case, giving them a lower bolus of phenobar, 130 milligrams once, can give you that synergy, can get you ahead of their symptoms, and then you can stay on top of it with more symptom-driven benzos, like more Ativan.
Speaker: Excellent.
Speaker: Why don't we dive a little bit deeper into the benzos and talk about the different options and how you view them in terms of treating alcohol withdrawal in the ICU?
Speaker: So this is one of those things that really seems to be very institution specific.
Speaker: Some institutions are much more diazepam, much more lorazepam fans.
Speaker: I've worked at hospitals that take both approaches.
Speaker: I think theoretically there are advantages to lorazepam.
Speaker: It tends to accumulate less in people who have hepatic dysfunction.
Speaker: It tends to cross the blood vein barrier a little bit better and cause more persistent CNS inhibition.
Speaker: So personally, my preference would be if you're going to use a benzo, use lorazepam.
Speaker: But I think there's plenty of places that use diazepam too, and I think it's a fine drug.
Speaker: We use a lot of midazolam in the ICU.
Speaker: This is one of the most common ICU sedation meds.
Speaker: So you might say, well, why are we not using that here?
Speaker: And it's a good question.
Speaker: I mean, we could just as easily use it.
Speaker: I think it just comes down to what your team is most comfortable dosing.
Speaker: I think the one big advantage of Ativan is that it has a longer duration.
Speaker: So, you know, especially in patients who are in a step-down unit or not in the ICU who can't be assessed as frequently, it can help control symptoms for longer.
Speaker: On that same note, the longest-acting benzodiazepine, chlorodiazoopoxide, or Librium, is really advantageous in that setting because it has a half-life up to 24 to 48 hours.
Speaker: And the reason why that is so useful is because it actually kind of self-tapers.
Speaker: It has active metabolites.
Speaker: So in somebody where you're worried they might elope from the hospital, it will actually sort of self-taper.
Speaker: It's also a good drug to potentially add other benzos on top of, where you can get quick symptom-driven sedation on top of a baseline level.
Speaker: And what about some words on using phenobarb?
Speaker: So phenobarb is a therapy for alcohol withdrawal, which is both older and newer.
Speaker: Before the benzodiazepines became the standard, this was what they used.
Speaker: And then phenobarb kind of went out of style.
Speaker: And now recently in the last five, 10 years, it's come back into style.
Speaker: And I'm a big fan of using Phenobarb in patients who are at high risk for severe withdrawal.
Speaker: And there's a couple of things I really like about it.
Speaker: Number one, you can give it as a loading dose and then it lasts for a long time.
Speaker: So you get the advantages of the long-acting benzo.
Speaker: Number two, it has a long half-life, so you're not chasing it as often.
Speaker: The big disadvantage of it though, is that you have to be really careful doing it in people who are on medications that have P450 interactions.
Speaker: So for example, people on like HIV meds, you have to be really cautious giving phenobarb because the levels are gonna be altered by that.
Speaker: You also have to be really cautious about synergy with benzos.
Speaker: That's both a good thing and a bad thing.
Speaker: A little bit can go a long way, but too much of it can cause over sedation.
Speaker: So personally, my practice is if somebody seems like they're at high risk for withdrawal and they haven't received a lot of benzos yet, I'll load them with phenobarb and go with a phenobarb strategy.
Speaker: If somebody has already received a lot of benzos or if they seem like they are having more mild symptoms and they're not at risk for severe withdrawal, I'll treat them with benzos because I know that my ICU nurses are great at assessing and escalating if necessary.
Speaker: In addition, I think, to those patients,
Speaker: that you mentioned that at super high risk, they're not received benzos.
Speaker: There might be patients who don't respond to benzos, right, or have other problems with benzos, in which case I think phenobarb and monotherapy probably would be the way to go.
Speaker: Absolutely.
Speaker: And, you know, there's a fascinating biology of GABA receptors.
Speaker: There are many different alternatively spliced variants in different parts of the brain.
Speaker: They can be assembled in different ways in different parts of the brain.
Speaker: So there's thousands of different GABA receptors and different people express them in different amounts.
Speaker: That's why some people tend to have more amnestic effects with benzos and other people don't.
Speaker: That's why some people tend to be really sedated with benzos and others aren't.
Speaker: And so there's a lot of personalizing the therapy to the patient required here.
Speaker: If somebody isn't responding to reasonable doses of benzos,
Speaker: the answer may not be higher doses.
Speaker: They may need a different therapy.
Speaker: Excellent.
Speaker: And my understanding of the literature, Nick, is that obviously most of the studies that have been done have not compared agents head to head.
Speaker: And they're really, a lot of the literature that we apply in the ICU comes from rehabilitation or kind of toxicology sites based studies.
Speaker: But in terms of monotherapy, really the only things that seem to be supported based on the pathophysiology are either benzos or phenobarbital.
Speaker: Is that correct?
Speaker: Correct.
Speaker: So there have not been many head-to-head studies, and the ones that have been done have been largely equivocal, right?
Speaker: Benzos and barbiturates are equivalent as monotherapy.
Speaker: There are some outcome studies that show that having multiple agents increases the frequency of bad outcomes.
Speaker: which kind of makes sense.
Speaker: The patients where you throw the kitchen sink at them tend to be the ones who are sicker.
Speaker: But I think that is a good argument to try to keep things simple.
Speaker: Try to pick one strategy or the other and use that.
Speaker: Though if the strategy isn't working, be prepared to change it.
Speaker: And I would like to touch on some additional medications that are often used as adjuncts and are very common in the ICU.
Speaker: And specifically, if you could give us your thoughts and what we know about propofol,
Speaker: and dexmeditomidine?
Speaker: So I think propofol is a great option in people who are intubated.
Speaker: I think it's a really risky option in people who are not intubated.
Speaker: So I think once somebody progresses to the point of requiring intubation, you should definitely use propofol.
Speaker: It has the advantage of being quick on, quick off.
Speaker: It has a strong GABAergic profile, so it corrects the underlying deficiency that causes alcohol withdrawal.
Speaker: Another drug that we use very often in the ICU and sometimes in alcohol withdrawal is dexmatomidine or Presidex.
Speaker: There was a lot of excitement about Presidex for alcohol withdrawal like 10 years ago.
Speaker: I think that one of the things that always worried me about this is that pharmacologically,
Speaker: Dexmatomidine acts as an alpha-2 agonist, so it blocks the sympathetic symptoms of alcohol withdrawal, but it doesn't really treat the underlying cause, which is inadequate GABA signaling.
Speaker: The studies on Prestidex in alcohol withdrawal have been mixed, to say the least.
Speaker: It likely does reduce the dose of benzos received, the patient received if you add Presidex.
Speaker: It may decrease the risk of intubation.
Speaker: It's definitely not clear that it makes your hospital length of stay shorter or improves any other outcomes.
Speaker: So I would say, you know, its role is controversial and it definitely doesn't keep things simple if you have to have a continuous infusion and other meds at the same time.
Speaker: So I think that's a downside potentially of it.
Speaker: Excellent.
Speaker: And I think it's important because like you said, in a lot of places, this has become a very popular and frequently utilized drug and understanding what it does and what it doesn't in alcohol withdrawal is important.
Speaker: Any comments on other medications like clonidine and haloperidol?
Speaker: Yeah, so I think to summarize it in a word, don't.
Speaker: It's always tempting to add more medications to treat more symptoms, but I think there are a couple of real downsides to adding more meds.
Speaker: So for example, there are studies that show that using antipsychotics like halodol actually cause worse
Speaker: Haloperidol can lower the seizure threshold.
Speaker: It can impair heat dissipation, potentially worsening hyperthermia.
Speaker: So as a rule, don't use haloperidol in people with alcohol withdrawal.
Speaker: Now the place where this gets complicated is what if somebody has delirium and alcohol withdrawal?
Speaker: Is it okay to use it there?
Speaker: The answer is probably yes, but there aren't any great studies.
Speaker: So as a rule, if I'm treating somebody for alcohol withdrawal, I try not to use antipsychotics.
Speaker: Clonidine, kind of like Presidex, blocks those autonomic symptoms.
Speaker: I think it's definitely got a role in treating milder withdrawal, especially in people who are not in the hospital, who are in like a all treatment setting.
Speaker: I generally don't use this in the hospital though, because it can cause bradycardia.
Speaker: And then finally, there's emerging literature about a lot of other agents.
Speaker: So baclofen and ketamine, right?
Speaker: basically been studied for everything in the ED and the ICU in the last 10 years.
Speaker: And there's some reason to be excited about these, ketamine blocks NMDA.
Speaker: So instead of increasing the inhibition, it turns down the excitation, it takes the foot off the gas to use our earlier analogy.
Speaker: Baclofen increases GABA signaling by another mechanism distinct from barbiturates and benzos.
Speaker: That said,
Speaker: The jury is still very much out on these.
Speaker: I don't think there's any compelling data.
Speaker: It's mostly theoretical.
Speaker: So I would say avoid for now.
Speaker: Stay tuned.
Speaker: There may be more studies on this in the coming years.
Speaker: So we really had to synthesize this.
Speaker: And as you mentioned when you were talking about the one-pagers, simple is always better, right, because it focuses on what's most important.
Speaker: But it seems that in general for people on the spectrum of lower acuity, symptom-based,
Speaker: with an objective score when they can participate is probably a good strategy.
Speaker: And people who are either sick or higher risk for having severe DTs or alcohol withdrawal seizures, maybe a little bit of front loading would be appropriate, followed by symptom-based.
Speaker: And really your options are, primary options are benzodiazepines and phenobarbital.
Speaker: You could use them together, but have to be careful.
Speaker: And then all the other medications that we mentioned are really adjuncts that come after
Speaker: you've utilized these two appropriately.
Speaker: Precisely.
Speaker: Let me ask you, Nick, about some special situations.
Speaker: We talked about withdrawal seizures, and obviously the treatment would be similar to alcohol withdrawal because that's what causes this and start with benzos.
Speaker: And like you said, loracepam might be a perfect place to start there.
Speaker: Is there any value in adding commonly utilized antiepileptics for these patients?
Speaker: So there are studies looking at using medications like phenytoin from decades ago that find that phenytoin versus benzos, benzos are superior.
Speaker: I think nowadays we tend to use more of a Kepra strategy.
Speaker: And I don't think there's any downside to that, especially in somebody where they might have both a history of alcohol withdrawal seizures and a seizure disorder.
Speaker: I don't think it's wrong to treat both like that.
Speaker: I think, you know, when there's a doubt, I usually lean a little bit more heavily on benzos and propofol if the person is intubated.
Speaker: If the person is not intubated, don't have a secure airway, then it's a little bit trickier and you have to sort of decide, you know, did this person have a short seizure?
Speaker: Now they're waking up, they have their mentation restored, in which case, you know, maybe air on the side of less treatment.
Speaker: It's definitely a tricky situation.
Speaker: And that's where talking to neurology can be very helpful.
Speaker: If somebody has been on anti-epileptic meds, you want to make sure they're getting them.
Speaker: And I generally talk to my consultant and say, hey, do you think we should check a level and load them with some more in that instance?
Speaker: Fair.
Speaker: What about this concept of resistant alcohol withdrawal?
Speaker: How do you define that if there's such a definition?
Speaker: And how would you approach that?
Speaker: So resistant alcohol withdrawal, there's no consensus definition based on symptoms, meds, treatment received.
Speaker: It's kind of like the famous Supreme Court definition of pornography.
Speaker: I know it when I see it.
Speaker: So resistant alcohol withdrawal is you've started treating them with one of these approaches and they're getting worse, not better, despite treatment.
Speaker: And this is the situation where I think this is a true medical emergency.
Speaker: You have to recognize that this person is sick and act aggressively to treat their symptoms because these are the patients where it can very quickly progress to DTs or seizures if you don't, if you fail to recognize how sick these patients are.
Speaker: So this is the common situation where somebody is admitted to, let's say the hospitalist service, they're on the wards,
Speaker: and they've gotten, let's say six or eight milligrams of Ativan in the last hour, and their symptoms have worsened in that time.
Speaker: That's a situation where you want to move that patient to the ICU, you want to think about whether they need phenobarb, higher doses of benzos, and you want to monitor them really closely because that's somebody where the next hour or two is usually going to be decisive and either get their symptoms under control or they're going to require escalation and intubation.
Speaker: And I think another point that we made before, but worth reemphasizing, is that one of the most important shortcomings that we have in clinical practice is not giving adequate doses of drugs, whether it be barbiturates or the benzos, and understanding that really some of these patients might require pretty large doses.
Speaker: Absolutely.
Speaker: And understand that there really is no max dose of benzodiazepines.
Speaker: You know, some of the
Speaker: When I was when I was at NYU, they, you know, they used to say, you know, two, four, six, eight, propofol intubate as like the Ativan escalation protocol.
Speaker: You know, I think there's there's a lot of there's a lot of timidity when it comes to treating alcohol withdrawal or people get a milligram at a time.
Speaker: And that really can be inadequate.
Speaker: You may need to double it, double it again.
Speaker: One of the big advantages of having a patient in the highly monitored setting of the ICU is that you can be aggressive about up titrating medications because you know that they're being monitored.
Speaker: And if you overdo it, as an intensivist, you can intubate them if need be, or you can monitor them closely to try to avoid intubation.
Speaker: But that's the big advantage of being in the ICU.
Speaker: It's not because they can get higher doses.
Speaker: It's because they can get higher doses safely.
Speaker: Yeah, good point.
Speaker: The last special situation group that I wanted to ask you about is you mentioned them at the beginning, which is patients who are hospitalized for non-alcohol withdrawal or non-alcohol related diseases who might be at high risk or might decompensate.
Speaker: Any words of advice for these post-surgical patients or other medical pathologies that we should be thinking of in the ICU?
Speaker: So this is something we see not uncommonly in patients who have surgeries, especially surgeries for like head and neck cancer.
Speaker: These patients are at risk for withdrawal.
Speaker: And one of the most important things to do is to monitor them closely for it.
Speaker: One question that often comes up is, why don't you use alcohol to treat alcohol withdrawal?
Speaker: Or why don't you use alcohol to prevent alcohol withdrawal?
Speaker: The answer is that in some cases we do.
Speaker: I know of hospitals
Speaker: where a person who's admitted for a simple fracture will be given one beer every four hours to prevent withdrawal.
Speaker: The reason why we don't do this and why I recommend not doing this in the ICU is because we don't know how to safely dose alcohol among critically ill patients.
Speaker: There really isn't any good data about intravenous alcohol in somebody who's on a ventilator with organ dysfunction, whereas we're very good at safely giving benzos in that population.
Speaker: Another thing that I hear a lot is, why do we keep doing this?
Speaker: Or why are we treating this person?
Speaker: They're just going to go drink again.
Speaker: And this is a very understandable frustration.
Speaker: I once saw a patient in a hospital gown at the gas station a block from my hospital who was trying to use his wristband to buy alcohol, his hospital wristband, his ID.
Speaker: And certainly if I had been treating that guy for alcohol withdrawal and then I saw him doing that, I'd be a little frustrated.
Speaker: But I think there's two really important things you have to remember whenever we find ourselves asking, why are we doing this?
Speaker: First of all, just because somebody has been admitted with alcohol withdrawal 10 times before doesn't mean that the 11th time won't be their last.
Speaker: I've heard from several people that the experience of going through withdrawal was so horrible and so horrifying
Speaker: that it's what prompted them to get soap.
Speaker: So helping somebody get through alcohol withdrawal, humanely and safely, can be the first step for them to turn their life away.
Speaker: Second of all, just remember that as people who work in the hospital, we have an availability bias.
Speaker: We only see the patients who keep getting admitted to the hospital.
Speaker: This makes it seem like none of our patients ever get sober because we only see people who are coming into the hospital with withdrawal.
Speaker: But in fact, many people do learn from this experience.
Speaker: They do get sober.
Speaker: We just don't see them.
Speaker: I think, Nick, that on that point, which is a very important one, is also
Speaker: Obviously, in the ICU, we're very focused with managing the acute episode and the life-threatening conditions, but also putting the wheels in motion through our social worker, our case management, and our other colleagues of maybe providing the right support or right information to these patients, giving them the opportunity to seek treatment once they leave the hospital for their addiction or their substance abuse is also important because you never know
Speaker: and who is going to work and might save their life.
Speaker: Absolutely.
Speaker: And you never know unless you try it.
Speaker: Occasionally, you may get a letter from a patient you treated years ago, but by and large, we don't get to find out about the patients where they do turn their life around.
Speaker: So it's a good assumption that everybody might do that if given the chance.
Speaker: Well, I think that we really covered a lot of ground.
Speaker: And like we said at the beginning, this is a very commonly encountered clinical syndrome that unfortunately has some dogma, but also some opportunity for us to be a little bit better at.
Speaker: And that really still requires, I think, a lot of research and a lot of data that is still not been produced, but definitely we'll keep track of it.
Speaker: Is there anything else that you want to add, Nick, as we go to our closing questions?
Speaker: I think I just did with the why do we keep doing this?
Speaker: I think that's something that, you know, there's always a lot of frustration with people who feel like patients keep bouncing back.
Speaker: And you just got to remember that, like, you know, alcohol withdrawal is a symptom of alcoholism, which is a disease.
Speaker: and compassion and treating these patients is the acute part of getting them better, but it's part of a larger process of them getting sober and, you know, treating this disease as a whole.
Speaker: I think that's a great point.
Speaker: So what we'd like to do, Nick, at the closing of the podcast is to just ask some questions that are unrelated to the clinical topic, but that definitely try to get a little bit of your overall wisdom and share it with our audience.
Speaker: Would that be okay?
Speaker: Sure.
Speaker: Excellent.
Speaker: So the first question relates to books.
Speaker: And are there any books that have influenced you significantly or books that you have gifted often to other people?
Speaker: Well, the two books that come to mind are Surely You're Joking, Mr. Feynman, which is just a fabulous sort of funny, quirky autobiography by the physicist Feynman.
Speaker: There's a lot of interesting stuff there that I learned.
Speaker: I think one of the key things that I get from him is that the best way to teach yourself is, the best way to learn is to teach others.
Speaker: You know, Feynman is just like a phenomenally, or was a phenomenally talented guy who did so many different things.
Speaker: And there's a lot of stuff that, you know, you can learn about from him.
Speaker: I really like his, he gave a speech once about cargo cult science.
Speaker: which is basically science that goes through the motions but isn't real.
Speaker: And I think that's, I wrote an article about this, you can find on my website, but I think it's very applicable now in the time of COVID.
Speaker: Another absolutely great book that I've given to a bunch of people is Sapiens by Yuval Noah Harari, just a really well-written philosophical book
Speaker: about what makes us who we are, what makes humans humans.
Speaker: And I just highly recommend it to everybody.
Speaker: Yeah, I think both are fantastic reads and highly recommend it.
Speaker: From Feynman, one of the things that has kind of stayed with me for many years, which I often repeat to my kids and they kind of roll their eyes, but I always tell them, the only person you can't fool is yourself and you're the easiest person to fool, right?
Speaker: just in terms of being truth to yourself and answering those tough questions that we all have, I guess, when we're alone with our thoughts.
Speaker: And sapiens, like you said, is really a tour de force of basically our species.
Speaker: And there's so much interesting things to learn there.
Speaker: So we'll definitely reference these in the show notes.
Speaker: The second question, Nick, relates to something that you believe to be true in medicine or in life that many other people don't believe or at least don't act like they believe it.
Speaker: So I think, you know, kind of circling back to where we started this conversation, I think there's a mistaken belief that the only way to teach and do research is to be in academic medicine.
Speaker: And I think that one of the really exciting things about FOMED and podcasts and this sort of larger world of alternative medical education is that you can participate in this either as a learner or as a teacher or both without a title.
Speaker: And I think we spend a lot of time worried about what the title is after our name instead of thinking about what work you actually want to be doing.
Speaker: And I just think that like one of the great things about podcasts like yours, websites like mine, is that you don't need a title to contribute to these things.
Speaker: You can contribute to these things by learning about a topic, being passionate about the topic, and then sharing that with others.
Speaker: Absolutely.
Speaker: And the last question or the closing question would be, what would you want every intensivist who's listening to us to know?
Speaker: Could be a quote, a fact, or just a thought.
Speaker: So I have this ever growing list of pet peeves, like, you know, don't say this, say this instead type stuff.
Speaker: We could waste a whole hour on that and I won't share that.
Speaker: But one of the things that I think we really ought to do in medicine more is think about the things that we're doing, quote, because we've always done them that way, and try to understand what the real reason is.
Speaker: And there's a great anecdote about this that I absolutely love, which is undoubtedly in medical school, you learned that if you want to check for fremitus, you put your hands on the person's back and you have them say 99.
Speaker: And if your hands shake, that's fremitus.
Speaker: That is completely wrong.
Speaker: It's a misunderstanding.
Speaker: It comes from the 19th century when American medical students went to study in Germany and there were these master clinicians did this, but they did it in German where it's 90-90, which has a diphthong.
Speaker: And so it's the diphthong sound that makes fremitus happen.
Speaker: But then, of course, when those people who didn't really understand why they were doing it, they were just taught to do it, came back to the US, they taught everybody to say 99.
Speaker: to elicit fremitis.
Speaker: So if you want fremitis, you need a diphthong sound, have the person say toy boat or something else.
Speaker: There are lots of examples of this, things that are like mistranslations, misunderstandings, or things that have outlived their usefulness.
Speaker: So I just, I love finding these things and sharing them because medicine is full of things that are done because, quote, we've always done them that way.
Speaker: It's not about old answers, but better questions, right?
Speaker: That's a good way to put it.
Speaker: Excellent.
Speaker: Well, Nick, I really enjoyed learning with you about alcohol withdrawal.
Speaker: Again, appreciate the one pagers.
Speaker: I find them super actionable and super practical for clinicians at the bedside.
Speaker: Encourage you to keep putting those out.
Speaker: I'd be looking forward for the one on nutrition, which is obviously a topic that has always a lot of opportunity.
Speaker: And I want to thank you for your time, for your expertise, and hope to have you back on the podcast soon.
Speaker: I'd love to be back.
Speaker: Thank you so much for having me.
Speaker: It's been great.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound's transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
