Phenobarbital versus benzodiazepine-based regimen for alcohol withdrawal syndrome in trauma patients

Introduction: Alcohol withdrawal syndrome (AWS) is associated with increased morbidity and mortality in the trauma population. Benzodiazepines (BZD) are standard of care for AWS; however, given the risk of delirium with BZDs and reports of BZD-refractory withdrawal, phenobarbital (PHB) has emerged as an alternative. Safety and efficacy studies of PHB for AWS in trauma patients are lacking. Our aim is to compare a BZD versus PHB regimen in the management of AWS in trauma patients. Methods: We performed a retrospective cohort study at a level 1 trauma center of patients at risk for AWS managed with either a BZD or a low dose oral PHB regimen. Patients were excluded if they were taking a study medication prior to admission, receiving propofol or dexmedetomidine prior to initiation of the study drug, presenting with delirium tremens or seizures, died, or were discharged within 24 hours of presentation. The primary outcome was complicated AWS (seizures or alcohol withdrawal delirium/delirium tremens). Secondary outcomes included uncomplicated AWS, therapy escalation, oversedation, delirium-, ICU-, and ventilator-free days, and length of stay (LOS). Results: 411 patients were identified; 118 received BZD, and 293 received PHB. The odds of developing complicated AWS with PHB versus BZD-based therapy was not statistically significant (OR 0.62; 95% CI, 0.23-1.69); however, patients in the PHB group were less likely to develop uncomplicated AWS (OR 0.09; 95% CI, 0.05-0.17) or require escalation of therapy (OR 0.47; 95% CI, 0.24-0.9). The PHB group had a LOS 3.26 days shorter than the BZD group (p=0.001). There was no difference in ICU-, ventilator-, or delirium-free days. Conclusions: PHB is a safe and effective alternative to BZD-based regimens in the management of AWS in trauma patients.