2026 Southeastern Residency Conference

Authors: Leah Franks, Jeremy Ray, and Mickala Thompson
 
Background: Alcohol withdrawal syndrome (AWS) is a serious condition that progresses in severity. The most severe symptoms include withdrawal seizures and delirium tremens. Phenobarbital is a barbiturate currently classified as an alternative agent for severe AWS in the 2020 American Society of Addiction Medicine’s “Clinical Practice Guideline on Alcohol Withdrawal Management.” A 2023 meta-analysis conducted by Umar, et al. concluded that phenobarbital can be used safely and effectively for AWS within the ICU setting. Phenobarbital prescribing practices have not been analyzed thus far at our institution. Therefore, the purpose of this research is to assess the current utilization and dosing schemes of phenobarbital for AWS at our large community hospital.
 
Methods: A single-center, institutional review committee-approved pre-post analysis was conducted at Huntsville Hospital to assess the safety, efficacy, and outcomes of patients receiving phenobarbital after the implementation of a streamlined-dosing order set. Information from an initial chart review was utilized to develop an order set based on current guideline recommendations/literature while also aligning with current prescribing practices at our institution. After implementation of streamlined dosing, a post-hoc analysis will be conducted. Adult patients, greater than 18 years of age, who received phenobarbital for management of AWS were included in the study. Exclusion criteria included vulnerable patients and those who received phenobarbital for underlying seizure disorders. The primary endpoints are the utilization of a pre-determined, guideline-directed dosing scheme and benzodiazepine usage post-phenobarbital loading dose administration. Secondary endpoints include ICU admission, need for intubation, withdrawal seizure or delirium tremens occurrence, and adverse events.
 
Results: A total of 54 patients in the pre-implementation group and 29 patients in the post-implementation group were included in this study. Baseline characteristics were similar between pre-post data regarding age (mean ~ 50 years), sex (majority male), baseline liver dysfunction (~50% for both groups), and receipt of CNS depressants (26% vs 21%) prior to phenobarbital. In terms of the primary endpoints, 38% of the providers utilized the phenobarbital order set. Benzodiazepine usage (in lorazepam equivalents - mg, median [IQR]) post-phenobarbital was comparable (4 [7.8] vs 4 [7.25]). Lastly, variability amongst secondary outcomes occurred with the need for ICU admission and the need for intubation post-phenobarbital between the pre-implementation group (56% and 13%) and the post-implementation group (31% and 21%).
 
Conclusion: Overall, order set utilization was minimal, which hindered appropriate comparison between pre-post implementation data. Limitations included the variety of ordering providers, a single center study, as well as the order set not initially being in all alcohol withdrawal order sets. Future directions include implementing further education across all provider types and improving visibility of the order set to providers by adding it to the overall alcohol withdrawal admission and add-on order sets.