2025 Southeastern Residency Conference

Title: Effect of phenobarbital administration in the emergency department for alcohol withdrawal syndrome on length of stay
 
Authors: Payton Mueller, Wesley Arrison, and Megan Cavagnini
 
Background: Alcohol withdrawal syndrome results from a disruption in neurotransmitter homeostasis related to gamma-aminobutyric acid (GABA) and glutamate activity. Benzodiazepines are considered first-line treatment for alcohol withdrawal while phenobarbital is considered an adjuvant agent and is the preferred alternative for patients experiencing severe withdrawal. Studies show that phenobarbital leads to lower rates of mechanical ventilation, reduces symptoms of alcohol withdrawal, and decreases intensive care unit (ICU) admissions. The purpose of this study was to compare the effect of one-time doses of intravenous phenobarbital administered in the emergency department (ED) with standard care for alcohol withdrawal syndrome on hospital length of stay.
 
Methods: This was a retrospective observational cohort study of patients with alcohol withdrawal syndrome who presented to the emergency department between January 1, 2020 to December 31, 2024 at a two-hospital health system. This study included patients 18 years or older that presented to the hospital via the ED and received treatment for alcohol withdrawal. Patients were excluded if they received multiple doses of phenobarbital, if they received phenobarbital outside of the ED, or if they were transferred from outside hospitals. Patients were identified using a computer-generated list using diagnosis codes for alcohol withdrawal and orders for phenobarbital or the institution’s alcohol withdrawal protocol. Subjects were matched in a 2:1 ratio in the standard of care group to the phenobarbital group based on baseline characteristics, demographic information, and patient reported frequency of alcohol use. The primary outcome was hospital length of stay. Secondary outcomes included admission location, intensive care unit length of stay, escalations in care, benzodiazepine use, use of adjuvant agents for alcohol withdrawal, and intubation rates.
 
Results: There were 165 patients included in this analysis (55 patients in the phenobarbital group; 110 patients in the standard care group). There was no difference in median length of stay between the phenobarbital group and the standard care group (3 days vs 2 days; p = 0.251). There were 11 patients in the phenobarbital group and 11 patients in the standard care group that required ICU admission (20% vs 10%, p = 0.075). Patients in the phenobarbital required a median of 45 mg diazepam equivalents compared to 22.5 mg diazepam equivalents in the standard care group (p = 0.592). Additionally, 25 patients in the phenobarbital group and 26 patients in the standard care group required at least one adjuvant agent (45.5% vs 23.6%; p = 0.004). There were also no differences between the phenobarbital group and standard care group in admission location (p = 0.224), escalation in care (3.2% vs 2.8%; p = 1), and intubation rates (5.4% vs 0.9%; p = 0.108).
 
Conclusions: This study found no statistically significant difference in hospital length of stay between the phenobarbital group and the standard care group. Patients that received phenobarbital were more likely to receive additional adjuvant agents compared to the standard care group. Additional prospective studies are needed to assess the impact of one-time doses of phenobarbital in the emergency department on clinical and safety outcomes.