2025 Southeastern Residency Conference

Authors: Nathan Doherty, Michael Saavedra
 
Objective: Analyze whether the use of phenobarbital reduced the length of hospital stay vs lorazepam in patients experiencing alcohol withdrawal.
 
Background: Alcohol withdrawal syndrome is a potentially life-threatening condition requiring immediate management. The American Society of Addiction Medicine (ASAM) recommends benzodiazepines, such as lorazepam, as the first-line treatment to prevent the signs and symptoms of alcohol withdrawal including seizures and delirium. Phenobarbital is advised as an alternative to benzodiazepines when benzodiazepines are contraindicated or as an adjunct to benzodiazepines. On June 5th, 2024, our health system added phenobarbital to our alcohol withdrawal order set for ICU patients. The objective of this project is to identify whether phenobarbital decreases the length of hospital stays for patients experiencing alcohol withdrawals when compared to lorazepam.
 
Methods: This single-center, retrospective cohort study included patients diagnosed with alcohol withdrawal syndrome who were treated with either phenobarbital or lorazepam at Parkridge Medical Center (PMC) and Parkridge East Hospital (PEH). Data was collected from electronic medical records to assess total hospital length of stay, incidence of delirium, and safety outcomes. Delirium episodes were identified based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Safety outcomes were evaluated by assessing the incidence of profound respiratory depression requiring respiratory support. Data was collected between June 5, 2024, and January 1, 2025. Statistical significance was determined using a Student's t-test.
 
Results: The average hospital length of stay (LOS) at PMC was 8.2 days for patients who received phenobarbital compared to 4.36 days for those who received lorazepam alone (P = 0.0070). At PEH, the average LOS was similar between the phenobarbital and lorazepam groups (3.79 vs. 3.91 days, P = 0.75). The incidence of delirium at PMC was 1.0 in the phenobarbital group versus 0.70 in the lorazepam group (P = 0.57). At PEH, the incidence of delirium was 0.65 for patients receiving phenobarbital compared to 1.16 for those receiving lorazepam (P = 0.094). Notably, no patients in either group required respiratory support following the initiation of phenobarbital or lorazepam.
 
 
 
Conclusion: A statistically significant difference in hospital length of stay at PMC was observed between patients who received phenobarbital versus those who received lorazepam alone. However, this finding is confounded by the presence of two significant outliers in the phenobarbital group (35 days and 20 days) and the small sample size (n=19). Additionally, a key limitation to phenobarbital use at our facility is the requirement for ICU monitoring, which may serve as a barrier to prescribing it over lorazepam. Notably, most patients at PEH presented with a chief complaint of alcohol withdrawal, whereas patients at PMC were critically ill, with alcohol withdrawal being a secondary diagnosis. This distinction may have contributed to prolonged hospitalization for patients in the PMC group, even after alcohol withdrawal syndrome was managed. Importantly, no patients in either group experienced respiratory depression requiring respiratory support. Given these findings, reconsideration of the ICU restriction for phenobarbital administration should be explored, as it may increase utilization and eliminate the need for inpatient phenobarbital taper completion, potentially expediting discharge. Future studies with larger sample sizes are warranted to further assess the impact of phenobarbital, either as monotherapy or in combination with lorazepam, on hospital LOS.


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