How is a dose escalation strategy used in the treatment of delirium tremens (DTs)?

Updated: Nov 06, 2020
  • Author: Michael James Burns, MD, FACEP, FACP, FIDSA; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, FAPS, MCCM  more...
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Answer

Some authorities advocate the use of a protocolized dose escalation strategy in treating patients with DTs in the ICU. In this strategy, patients with DTs are treated with escalating doses of diazepam with titration of phenobarbital according to the patient's score on the Riker Sedation Agitation Scale (RSAS) (goal 3-4) or the Richmond Agitation Sedation Scale (RASS) (goal 0 to -2). In this approach, diazepam is administered intravenously at escalating doses every 10-15 minutes up to 100-150 mg per dose (or lorazepam IV up to 30 mg per dose) with calculation of the RSAS or RASS after each dose. If the patient reaches the goal, then that dose is used as the maintenance dose. If the goal on the sedation score is not reached, phenobarbital is administered intravenously at repeated doses of 65-260 mg until the desired goal is reached. In retrospective cohort studies, this strategy, compared with a nonprotocolized strategy, appeared to be effective in reducing rates of mechanical ventilation and length of ICU stay. If that fails, then mechanical ventilation and treatment with propofol should be considered. Other drugs to consider when benzodiazepines and phenobarbital are not effective include dexmedetomidine or ketamine. There are no randomized prospective controlled trials of this strategy. [9, 10, 11]


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