Prealbumin Levels and Delirium Tremens

Marcey Furlow, RN, CCRN, SRNA

Hamot Medical Center School of Anesthesia/Gannon University

• 63 year old male• 85 kg 70 inches• Planned Surgery: Bilateral Total Knee

Replacement

• PMH: HTN, hyperlipidemia, bruises easily, hypothyroidism, peripheral neuropathy, GERD, depression, consume alcohol almost every day “but not a lot”, denies smoking

• PSH: Right knee arthroscopy, cystoscopy x 2, TURP, left shoulder SLAP repair, No history of problems with anesthesia

Clinical Scenario

Clinical Scenario

• EKG- NSR with possible LVH and atrial enlargement

Clinical Scenario

CXR- no acute pulmonary disease, moderate pulmonary hyperinflation, moderate cardiomegaly

Clinical Scenario

• Bilateral femoral catheters placed for post-op pain control

• Operation was uneventful • Post-op course:

• Day 1: pt slightly agitated, family states that his disposition is normal

• Day 2: pt still agitated, slightly tachycardic, HR 100’s, complaining of headache. Given Ativan, Norco, and Lopressor restarted from home med list. Still agitated when awake but very drowsy, HR decreased to 70’s

Clinical Scenario

• Post-op course: (cont.)– Day 3: Hallucinating, physical therapy notices a decline

in patient’s coordination. Patient falls during physical therapy is taken back to his room and has a seizure.

Clinical Scenario

• What happened?

Presentation Objectives

• Describe effects of chronic alcohol consumption on the brain

• Learn about alcohol withdrawal syndrome and delirium tremens

• Recognize a link between nutrient deficits and neurologic disorders

• Review research comparing prealbumin levels and incidence of delirium tremens

• Understand relevance to a CRNA’s practice

Statistics

• Nearly 27% of adults (age 18-64) meet the criteria for alcohol dependency (2005, McKinley)

• Medical costs related to alcohol abuse, both acute and chronic, are estimated to be 100 billion dollars a year (2004, Baynard)

DSM-IV Criteria for alcohol dependence

• At least three out of seven of the following criteria must be manifest during a 12 month period:– Tolerance– Withdrawal symptoms or clinically defined Alcohol Withdrawal

Syndrome– Use in larger amounts or for longer periods than intended– Persistent desire or unsuccessful efforts to cut down on alcohol use– Time is spent obtaining alcohol or recovering from effects– Social, occupational and recreational pursuits are given up or

reduced because of alcohol use– Use is continued despite knowledge of alcohol-related harm

(physical or psychological)

Possible Long-Term Effects of Alcohol

Areas of the Brain Affected by Alcohol

Comparative PET scan (PET=positron emission tomography)

NMDA Receptors(N-methyl-d-aspartate receptor)

• Excitatory • Neurotransmitter- Glutamate• Blocked by acute ingestion of ETOH• Up-regulated due to chronic consumption of

ETOH

GABA Receptors (γ-aminobutyric acid receptor)

• Inhibitory• ETOH binds to receptor and increases Cl-

influx• Down- Regulated by chronic ETOH

consumption

• GABA remodeling

Alcohol Withdrawal Syndrome

• Symptoms develop approximately 48-72 hours following last drink

• Prophylaxis- multivitamins, folic acid, thiamine and low to moderate dose benzodiazepines

• Treatment- high dose benzodiazepines• CIWA- Assessment

Signs and Symptoms of Alcohol Withdrawal Syndrome

• Agitation/Anxiety• Confusion• Depression• Diaphoresis• Fear• Panic Attacks• Headache• Hyperthermia

• Tachycardia

• Palpitations• Tremors • Weakness• Hypertension• Gastrointestinal Upset

Delirium Tremens Latin for “shaking frenzy”

• First described in literature approximately 200 years ago

• Most severe form of alcohol withdrawal syndrome

• Exact etiology still unknown• Hypothesized that the sudden decrease in

alcohol unmasks remodeled receptors resulting in an extreme hyper-excitable state

• Progression from alcoholic withdrawal syndrome

• Severe autonomic instability and hyperactivity• Intense visual disturbances and hallucinations• Severe uncontrolled tremors• Seizures• Mortality is approximately 5% when treated

and 35% untreated

Delirium Tremens

Isolated Risk Factors for Developing Delirium Tremens

• Presence of infectious disease• Severe tachycardia • Over activity of the nervous

system while patient is still intoxicated

• Previous history of delirium tremens

• Concurrent epileptic disorders and multiple co-morbidities

Wenicke-Korsakoff Syndrome

• Combination of Wernicke’s encephalopathy and Korsakoff’s psychosis

• Results from a Vitamin B1 (Thiamine) deficiency causing damage in the thalamus and hypothalamus

• Signs and Symptoms:– Ataxia -- Leg tremors– Confusion -- Double vision– Memory loss -- Nystagmus – Hallucinations

Conceptual Framework

• Evidence based application• Lutz and Przyulski (2006)- Identified the role of

pyridoxine (vitamin B6)• Co-enzyme in the synthesis and catabolism of

amino acids including neurotransmitters • Involved in the metabolism and synthesis of over

100 enzymes• Pyridoxine must be ingested, deficiency is rare in

the general population but common in people with chronic alcohol ingestion

Nutrition Deficits Associated with Chronic Alcohol Consumption

• Vitamin B– B1 (Thiamine)– B2 (Riboflavin)– B3 (Niacin)– B6 (Pyridoxine) – B12 (Cobalamin)

• Vitamin C• Vitamin D

• Folic Acid• Vitamin K• Vitamin A• Phosphate • Magnesium• Amino Acid/Protein

Prealbumin (transthyretin)

• Carrier protein esp. (thyroxine and retinol)• Found in blood and CSF• Routinely used to determine nutrition status• Lab value reflects current nutrition status due

to sensitivity of 2-4 days

Half Life (days)

Normal Levels (mg/dL)

Malnutrition (mg/dL)

Mild Moderate Severe

2-4 15.7-29.6 12-15 8-12 < 8

Statement and Significance of the Problem

• Delirium tremens is an acute—sometimes fatal—psychotic reaction caused by cessation of alcoholic beverages

• Patients who develop delirium tremens have prolonged and complicated hospital stays

• Medical treatments are mostly reactionary, not proactive or preventative

• Quantitative, descriptive research study

• Retrospective chart review

• Setting 375 bed urban medical center in northwestern Pennsylvania

Research Design

Sample Demographics

• Out of 464 charts reviewed 24 met the inclusion criteria

• 12 patients who experienced delirium tremors and 12 patients who did not were included

• Each sub-group was comprised of 11 men and 1 woman

Prealbumin results

Group Range (mg/dL) Mean (mg/dL) Median (mg/dL)

Delirium Tremens 3.9-42.5 17.8 16.1

Non Delirium Tremens

13.3-42.3 27.9 28.2

Overall sample 3.9-42.5 22.5 24.4

Prealbumin levels for the delirium tremens group were on average 10.1 mg/dL lower

Statistical Analysis

• Analysis using a paired t test found the difference significant at the .001 level

• These findings suggest there is a 99.9% chance that the levels are significantly different

Limitations

• The sample size was small• Lack of a set diagnosis criteria for Delirium

Tremens• Inability to control extraneous variables • Prealbumin is not a routine lab for patients

with chronic alcohol abuse• Patients with liver disease were not excluded

Recommendations for Future Research

• Larger Sample size• Prospective study so that variables can be

controlled • Increased exclusion criteria

Relevance to CRNA Practice

• Identifying risk factors may aide in early identification and proactive treatment

• Elective procedures with subsequent hospital admission could be discouraged d/t increased patient risk

• To assist in differential diagnosis

• To add to a CRNA’s body of knowledge

Special Thanks:

Dr. Sharon J. Thompson, PhD, RN, MPH Chairperson of Thesis Committee

Krista L.Yoder, MSN, CRNA Program Director/Thesis Committee

Tara Morrison, MSN, CRNA Thesis Committee

Carin Shollenberger, BSN, RN, SRNA co-researcher

Greg McMichael, MSN, SRNAco-researcher

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