Alcohol Abuse

Description

Alcohol abuse is a chronic disease with profound societal implications. More than 19% of cases resulting in deaths of young automobile drivers were related to alcohol. Additionally, the annual total cost of alcohol-related problems reaches a staggering $180 billion.
Both acute alcohol intoxication and chronic alcohol abuse can increase anesthetic complications.

Epidemiology

Prevalence

In the US, the rate of alcohol use disorders, including abuse and dependence, is ~8.26%; this correlates to ~15 million people.

Morbidity

In the perioperative period, patients with alcohol abuse have been shown to have an increased risk of infections, bleeding disorders, need for ventilator support, and cognitive dysfunction.
Maternal alcohol consumption during pregnancy can lead to fetal alcohol disorders; 1% incidence.

Mortality

Alcohol withdrawal during surgery may be associated with a mortality rate as high as 50%.
Alcohol use is the third leading cause of preventable death in the US, and accounts for ~85,000 deaths annually.

Etiology/Risk Factors

Gender: Men are 5 times more likely than women to develop alcohol abuse.
Family history: The rate of alcohol abuse is about 30% in men with one alcoholic parent.
Genetic factors: May affect the process and response to alcohol in the human body
Cultural factors: The high rate of alcohol abuse in the US and Europe may relate to the common use and social acceptance of alcohol use.
Psychiatric disorders: Higher in persons with depression, anxiety, antisocial behaviors, post-traumatic stress disorder, high self-expectations, or low frustration tolerance

Physiology/Pathophysiology

Alcohol has been shown to affect the following receptors in the human brain:
- GABA: Alcohol binds to the GABA receptor and increases chloride ion movement into the cell with resultant hyperpolarization (decreases neural activity, by making the cell membrane potential more negative). Responsible for the sedative and anxiolytic effects (similar to hypnotic drugs and benzodiazepines).
- Glycine: Alcohol binds to the glycine receptor and potentiates its role as the major inhibitory neurotransmitter in the spinal cord and brain stem.
- Serotonin: Alcohol increases levels either via increased release and/or decreased breakdown, as well as potentiates its effects on receptor function. Serotonin may enhance the release of other neurotransmitters that play a key role in tolerance and contribute to alcohol withdrawal syndrome (AWS).
- Glutamate: Alcohol decreases glutamate's excitatory effect on NMDA receptors. Chronic consumption, however, makes NMDA receptors hypersensitive to glutamate while desensitizing the GABAergic receptors; believed to play a role in AWS.
- Opiates: Alcohol induces the release of endogenous opioid peptides (can cause euphoria and blunt the sensation of pain). The body's endogenous opioid system (enkephalins, endorphins) is linked with the brain's reward pathway; may play a role in addiction.
- Dopamine: The increased levels/effects that are seen with alcohol abuse is a poorly understood mechanism. It has been postulated to result from disinhibition of dopaminergic neurons, decreased breakdown, and increased release. Dopamine pathways play a role in reward and reinforcement and may play a role in addiction.
Alcohol is absorbed directly through the stomach wall (~20%) and small intestines (~80%). The liver functions to break down alcohol.
Effects on other organs may result from direct inflammation or possibly from "blood sludging." Blood sludging describes the clumping of red blood cells with resultant plugging of small vessels, ischemia, and cell/tissue death distally. The increased pressure can result in capillaries breaking (red eyes, blotchy skin, "drinker's nose").

Anesthetic GOALS/GUIDING Principles

Preoperative evaluation should determine concomitant organ dysfunction. A high index of suspicion for alcohol cardiomyopathy should be present, as this is often underdiagnosed.
Prevent aspiration in patients with cirrhosis and ascites
Anticipate prophylaxis and treatment of alcohol withdrawal and delirium tremens

Diagnosis ⬆ ⬇

Symptoms

A high index of suspicion is required to diagnose alcohol abuse.
Nonspecific, but suggestive, symptoms include gastritis, tremor, and history of falling.

History

Despite the brief preoperative encounter, a social history including alcohol use should be elicited. If suspected, consider further focused questioning.
Alcohol Use Disorders Identification Test (AUDIT) is 92% effective in detecting hazardous or harmful drinking. A total score of 8 indicates harmful drinking behavior. It is also helpful in identifying those at greatest risk for postoperative complications.
Inquire about other substances of abuse

Signs/Physical Exam

Usually nonspecific; abnormalities are usually related to the systemic diseases associated with chronic use.
"Drinker's nose": A purple nose that results from tiny broken capillaries

Medications

No specific medications, unless being treated for abuse.

Diagnostic Tests & Interpretation

Labs/Studies

Glucose: May be low, particularly in diabetics
CBC with platelets: Anemia
Liver function tests, PT and aPTT: May be abnormal due to alcoholic hepatitis or cirrhosis.
EKG: May show left ventricular hypertrophy and arrhythmias.
CXR: May show aspiration, pleural effusions and cardiomegaly.

CONCOMITANT ORGAN DYSFUNCTION

Nervous system: Cerebellar degeneration, tremors, delirium tremens, dementia, depression, memory loss, Wernicke–Korsakoff syndrome, peripheral neuropathy (burning, numbness, weakness)
Cardiovascular: Alcoholic cardiomyopathy, hypertension
Pulmonary: Aspiration, pleural effusion, and pulmonary hypertension (may occur in end stage liver disease).
Hepatic: Alcoholic hepatitis, cirrhosis
Gastrointestinal: Absorption of B vitamins and other nutrients may be impaired. Gastritis, ulcers, and increased risk of stomach cancer. Acute and chronic pancreatitis; may eventually result in diabetes.
Metabolic: Impairs fat and glucose metabolism in the liver and pancreas. Acute alcohol ingestion can result in a steep rise in blood sugar that is met by an increased release of insulin, with resultant hypoglycemia.
Hematologic: Anemia can result from malnutrition or direct suppression of bone marrow.
Malnutrition is very common and can lead to anemia (folic acid, vitamin B12 deficiency), or hypoalbuminemia (low protein intake) and Wernicke–Korsakoff syndrome (vitamin B1 deficiency).
Other: Sexual dysfunction (decreased testosterone), birth defects, osteoporosis

Circumstances to delay/Conditions

Elective surgery should be postponed in patients with acute alcohol toxicity, alcoholic hepatitis, or decompensated systemic diseases.
Treatment of alcohol abuse or dependence should be considered before elective surgery in order to decrease perioperative morbidity and mortality.
Severe dehydration or electrolyte imbalance should be corrected prior to surgery.

Classifications

Alcohol abuse is defined by the following characteristics: Drinking even when it is dangerous; excessive drinking; legal problems related to drinking; and interpersonal problems with family, coworkers, and friends because of alcohol use.
Alcohol dependence (alcoholism) is characterized by: Drinking excessive amount frequently; the inability to stop drinking despite social, psychiatric, or medical complications; increased tolerance of alcohol; and the occurrence of alcohol withdrawal symptoms when drinking is discontinued.

Treatment ⬆ ⬇

PREOPERATIVE PREPARATION

Premedications

Benzodiazepines are helpful in reducing anxiety and preventing withdrawal.

INTRAOPERATIVE CARE

Choice of Anesthesia

Regional anesthesia (spinal, epidural, or peripheral nerve blocks) may decrease systemic effects and CNS disturbance with general anesthesia. It is also easier to monitor mental status changes in awake patients, especially in those at risk of alcohol withdrawal. In patients with liver disease, however, coagulopathy may preclude neuraxial techniques.

Monitors

Standard ASA monitors
Invasive monitoring may be considered when alcoholic cardiomyopathy is suspected or present, and depending upon the surgical procedure.

Induction/Airway Management

Acute alcohol intoxication may reduce anesthetic dose requirement.
Chronic alcohol abuse may require higher anesthetic doses due to cross-tolerance (e.g., increased propofol induction doses). Cirrhotics have an increased volume of distribution which may necessitate increased doses (but may have increased sensitivity to drugs and decreased clearance). In alcoholic cardiomyopathy, intravenous induction should be accomplished by careful titration to avoid hypotension.
Rapid-sequence induction with cricoid pressure should be considered in patients with delayed gastric emptying due to ascites. Intoxicated trauma patients are at an increased risk for aspiration.

Maintenance

In cirrhotic patients, maintenance doses may need to be decreased due to impaired liver metabolic function.
Non-depolarizing muscle relaxants should be cautiously titrated due to impaired hepatic function.
"Banana bag" infusion may be considered.

Extubation/Emergence

Normal extubation criteria apply; however, alcoholics may have impaired clearance of muscle relaxants and gastric motility. Ensure full recovery from NMBDs and a protective gag reflex.

Follow-Up ⬆ ⬇

Bed Acuity

ICU admission may be required if alcohol withdrawal or delirium tremens is suspected.
Supplemental oxygen should be provided, especially when the patient is receiving narcotics.

Complications

AWS may be seen in patients who abuse or are dependent on alcohol when they stop drinking abruptly because of injury, surgery, or acute illness. Typically develops 6–24 hours after their last drink. Symptoms are related to autonomic hyperactivity and include sweating, nausea, vomiting, anxiety, agitation, tachycardia, and hand tremor. Neuronal excitation, including grand mal seizures, usually occurs within 24–48 hours of abstinence. Delirium tremens is the most intense and serious form of AWS. It is characterized by visual or auditory hallucinations, confusion, clouding of consciousness, impaired attention, and pronounced autonomic hyperactivity. It usually appears 2–4 days after the patient's last use of alcohol. Death from cardiovascular and respiratory collapse may occur, if untreated. Prophylaxis is with benzodiazepines. Treatment of AWS involves establishing the diagnosis and severity with the CIWA-Ar Score and transferring to the ICU. Medical treatment involves a combination of benzodiazepines, haloperidol, clonidine, and beta-blockers; in some instances, a drink with meals may be ordered. Supportive care includes the treatment of nutritional deficiency, hypoglycemia, arrhythmias, congestive heart failure, alcoholic hepatitis, alcoholic pancreatitis, GI bleeding, and nervous system impairment.
Postoperative cognitive dysfunction is increased in patients aged 55 years and older after noncardiac surgery with general anesthesia.
Increased risk of infections may be due to alteration of T-cell mediated immunity as well as altered immune response to surgical stress.

References ⬆ ⬇

Lian J , Cagetti E , Richard W , et al. Altered pharmacology of synaptic and extrasynaptic GABAA receptors on CA1 hippocampal neurons is consistent with subunit changes in a model of alcohol withdrawal and dependence. J Pham and Exp Therap. 2004;310(3):1234–1245.
Lovinger DM. Serotonin's role in alcohol's effects on the brain. Alcohol Health Res World. 1997;21(2):114–120.
Publications from the Institute on Alcohol Abuse and Alcoholism, NIH. www.niaaa.nih.gov.
Spies CD , Rommelspacher H. Anesthestic alcohol withdraw in the surgical patients: Prevention and treatment. Anesth Analg. 1999;88:946–954.

Additional Reading ⬆ ⬇

See Also (Topic, Algorithm, Electronic Media Element)

Alcohol Cardiomyopathy
Pregnancy Substance Abuse
Cirrhosis
Alcohol Withdrawal Syndrome

Codes ⬆ ⬇

ICD9

303.90 Other and unspecified alcohol dependence, unspecified
305.00 Alcohol abuse, unspecified
305.01 Alcohol abuse, continuous

ICD10

F10.10 Alcohol abuse, uncomplicated
F10.129 Alcohol abuse with intoxication, unspecified
F10.20 Alcohol dependence, uncomplicated

Clinical Pearls ⬆ ⬇

AUDIT (Alcohol Use Disorders Identification Test) utilizes 10 questions; scoring is on a scale of 0–4 per question. A total score of 8 indicates alcohol abuse or dependence. (Note: A unit is equal to one small glass of wine, a single purchased measure of spirits or half a pint of beer.) The questions include:

How often do you have a drink containing alcohol?
How many units of alcohol do you drink on a typical day when you are drinking?
How often do you have 6 or more units of alcohol on one occasion?
How often during the last year have you found that you were not able to stop drinking once you had started?
How often during the last year have you failed to do what was normally expected from you because of drinking?
How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
How often during the last year have you had a feeling of guilt or remorse after drinking?
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Have you or someone else been injured as a result of your drinking?
Has a relative or friend or doctor or another health worker been concerned about your drinking or suggested you should cut down?

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Basics ⬇