Detection window – 2-12 hours

Screen for unhealthy alcohol use – ask the question “How many times in the last year have you had 5 or more drinks (4 for women) in a day”. Any answer greater than 1 suggests unhealthy alcohol consumption and the patient should be further questioned to assess the degree of alcohol dependence.

Withdrawal – the most serious postoperative complication is alcohol withdrawal syndrome (AWS) and delirium tremens. Withdrawal intensity and onset depends on the degree of alcohol dependence. It is good practice to ask the patient when withdrawal begins and how much alcohol is consumed on a day-to-day basis. For alcohol dependent patients, mild withdrawal symptoms typically begin at approximately 6 hours and gradually increase in intensity to peak at 72 hours. Symptoms can include headache, abdominal irritation, tremors, hallucinations, siezures, febrility, and tachycardia. The worst of these (tachycardia, seizures, febrility, and severe hallucinations) is called AWS and is a life-threatening condition. Ongoing monitoring for withdrawal symptoms should continue after surgery if the possibilities of withdrawal are suspected. Manifestations would present as a stress response during surgery and in phases where typical signs/symptoms are difficult to assess.

Withdrawal prophylaxis – Recommendations are to use benzodiazepines and to AVOID alcohol in the treatment and prevention of withdrawal symptoms. Prophylaxis is recommended for any patient suspected of frequent heavy alcohol use. This should begin at the beginning of abstinence from alcohol or on admittance to the hospital. Chlordiazepoxide 25-100 mg every 6 hours for the first day, and 25-50 mg every 6 hours for the following 2 days is the recommended approach. Alternatively, diazepam 2.5 to 10 mg or lorazepam 0.5 to 2 mg can be used in the same intervals/frequencies.

Drug dosages – drugs that depress the CNS, such as propofol and fentanyl, typically require higher dosages if the patient is alcohol dependent. Conversely, if the patient is acutely intoxicated, the patient typically requires smaller dosages to achieve therapeutic goals.

Aspiration risk – alcohol reduces the lower esophageal sphincter pressure. If acutely intoxicated, treat as a full stomach.

O2 titration – acutely intoxicated patients have less tolerance for hypoxia. By default, you should give 100% FiO2 and titrate.

Liver damage – Always consider that the patient may have a degree of liver damage/cirrhosis. This can manifest with as an abnormal INR, albumin, and/or AST/ALT. Malnutrition, bleeding, immunocompromise, and slowed elimination of hepatic-metabolized drugs all become more likely with hepatic impairment.

Fluids – Replacement of fluids requires special consideration of the patient’s condition. Severe vomiting, electrolyte values, and/or cirrhosis are all considerations when giving fluids. Ethanol has an inhibitory affect on ADH, which is responsible for increased diuresis during intoxicated states.

Bleeding Risk – Significantly higher bleeding times and cases requiring transfusions have been documented in alcohol dependent patients.

Infection and Healing – alcoholism is an independent risk factor for postoperative wound infections. Alcoholism also contributes to slower healing and immunocompromise.

Substance abuse (general considerations) – If necessary, get your urine/blood screen early. The urine screen will take 30 minutes and a serum screen will be closer to an hour. Almost all drug screens will return results for marijuana, amphetamines/methamphetamines, phencyclidine (PCP), cocaine, opioids, barbiturates, and benzodiazepines. Generally speaking, if the patient is acutely intoxicated, the case should be cancelled/delayed. Refer to your facility to get policies on cancellations/delays.

Alcohol is the most abused drug worldwide.

Incidence – up to 28.5% of those presenting for surgery will have an alcohol abuse disorder. The highest incidence is in obese patients presenting for bariatric surgery.

Elimination – Blood levels of alcohol decrease by approximately 0.015 g/dL per hour. This number may be considerably lower in patients with cirrhosis or liver failure.