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  • Elisa Migliozzi
  • Letters

Use of fluids to treat patients with acute alcohol intoxication: are they really effective?

  • 3/2017-Ottobre
  • ISSN 2532-1285
  • https://doi.org/10.23832/ITJEM.2017.028
Migliozzi E. (1), Baldini E. (1), Ceccanti M. (2)
1) Emergency medicine Sapienza Rome University
2) Head of the Latium Region Alcohol Referral Center-  Sapienza – University of Rome
It is common practice to use saline solution (0.9% sodium chloride) to treat patients with acute alcohol poisoning1 despite the lack of scientific evidence for its efficacy2,3.
Fructose infusion can also be used to enhance alcohol metabolism, however its administration can further increase plasma osmolality (already elevated because of ethanol ingestion) and possibly cause lactic acidosis4. This is the reason why this treatment is not recommended and saline infusion is more frequently used1,2.
In this regard it is worth mentioning a study conducted in one of the Emergency Departments in Queensland (Australia). It compares uncomplicated alcohol-intoxicated patients treated with saline solution (0.9% sodium chloride) plus observation, with a control group presenting the same characteristics but only treated with observation5. The main outcome of this research is the evaluation of the effectiveness of fluid therapy in reducing patients’ intoxication levels and length of stay in the ED (therefore costs).
It is indeed common medical practice to use fluids with the aim of lowering alcohol levels and its metabolites, reducing its neuro-depressive effects, and making patents spending less time in the ED. However, it is desirable to explore their use to ensure that the health benefits outweigh potential harms, such as infection and fluid overload.
In the aforementioned study there were first identified 626 patients presenting with acute alcohol poisoning as their primary diagnosis. Of these 626 were only included those patients aged 18 to 50 not presenting any psychiatric or neurological preconditions or requiring airway support. 144 patients resulted eligible for the study; of these 144, 73 were treated with a single bolus of 20mL/kg normal saline infusion, and the other 71 constituted the observational group.
Results showed no significant difference between the two groups in terms of length of stay in the ED, and general state of intoxication. These findings are in discordance with the common medical perception that fluids administration makes patients sober faster enabling swifter discharge1,2. At 2 h, the only relevant change between the two groups was the faster decrease in breath alcohol level (BAL) in the treatment group, however this did not determine a faster discharge.
Finally, intra-hospital costs were higher for patients in the treatment group; these are to be attributed to the administered saline solutions and to the higher intensity of care required (Tab 1).
 

Tab.1 Emerg Med Australas. 2013 Dec; 25(6): 527–534.Published online 2013 Nov 8. doi: 10.1111/emm.12151 – S. Perez, M. Steele, J. Byrnes, P.A. Scuffham

This very interesting and thought-provoking study has its own limitations:

  • It only includes “ideal patients” – those affected by acute alcohol poisoning as their primary diagnosis and not presenting any pathologies;
  • It does not take into account the initial blood alcohol content which could differentiate patients and types of treatment on the basis of the necessity of reducing alcohol’s damaging effects;
  • It does not take into account the blood sodium level – sodium infusion in a patient with low blood sodium can cause sodium levels to rise too quickly and the consequent development of pontine myelinolysis;
  • Although due to the necessity of the two groups to have similar demographic and clinical characteristics, the number of patients recruited for the study is much lower than the initial one;
  • The dose of i.v. normal saline given to the treatment groups is the same in all cases; it could have been useful to differentiate it in relation to the clinical characteristics of the study population.

Despite these limitations, the study suggests there is no evidence that fluids administration delivers a better outcome to the treated patients neither in terms of improvement in intoxication scores, nor in changes in alcohol clearance, nor in enabling earlier discharge3.

The question remains as to whether in some carefully selected patients the administration of saline solution (0.9%) would obviate the volume depletion caused by ethanol-induced diuresis, poor fluid intake and vomit6,7. Hydration also helps preventing metabolic disorders such as acidosis or alkalosis, hpo or hypernatremia, hypokalaemia from occurring8,9,10.

In managing these clinical situations, the real issue – very well known in the literature – becomes the ability to identify and differentiate patients who have needs for medical care from those that only require observation9,10. Similarly we could select those who need a blood alcohol test or a head CT.

There are no easy answers; we know that a discrepancy between level of consciousness and blood alcohol concentration or delayed awakening are commonly used criteria, but it is not so simple to establish general rules of behaviour. Surely the most feared metabolic disorder is metabolic acidosis, which, if downplayed, could be fatal11,12,13.

To sum up, there seems to be no scientific evidence that fluid therapy should be used in all cases of acute alcohol intoxication, but it is advisable to reserve it to those patients with hydro-electrolytic alterations or only where deemed necessary.

 

Bibliography

  1. Hindmarch PN, Land S, Wright J. Emergency physicians’ opinions on the use of intravenous fluids to treat patients intoxicated with ethanol (alcohol): attitudes of emergency medicine physicians in the North East of England toward the use of intravenous fluids to treat individuals intoxicated with ethanol (alcohol) attending the emergency department compared with the scientific evidence. Eur. J. Emerg. Med. 2012; 19: 379–83.
  2. Sanaei-Zadeh H. Use of intravenous fluids for the treatment of patients intoxicated with ethanol (alcohol): is it a scientific-based practice?  Eur. J. Emerg. Med. 2012;19: 409–410.
  3. Li J, Mills T, Erato R. Intravenous saline has no effect on blood ethanol clearance. J. Emerg. Med. 1999; 17:1–5. 
  4. Mascord D, Smith J, Starmer GA, Whitfield JB The effect of fructose on alcohol metabolism and on the [lactate]/[pyruvate] ratio in man. Alcohol Alcohol. 1991;26(1):53-9.
  5. S. R. Perez, G. Keijzers, M. Steele et al. Intravenous 0.9% sodium chloride therapy does not reduce length of stay of alcohol-intoxicated patients in the emergency department: A randomised controlled trial. Emerg Med Australas. 2013 Dec;25(6):527-34. doi: 10.1111/1742-6723.12151. Epub 2013 Nov 8.
  6. Finnell J, Marx JA, Hockerberg RS. Alcohol-related disease In: Rosen P. et al., editors. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Pennsylvania: Mosby Elsevier; 2010. pp. 2378–2394.
  7. Moulds R, Brett J, Buckley N, et al. Alcohol overdose Therapeutic Guidelines. 2008. Available from URL: https://online-tg-org-au.cknservices.dotsec.com/ip/
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  10. World Health Organization. Collaborative study on alcohol and injuries: final report. 2007. WHO. Available from URL: http://www.who.int/substance_abuse/publications/alcohol/en/index.html.
  11. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974; 304:81–84. 
  12. World Health Organization. ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines 1992. WHO.
  13. Available from URL:http://www.who.int/substance_abuse/terminology/icd_10/en/index.html.
  14. Queensland Health. Nursing and midwifery wage rates – Queensland Health 2012. [April ].
  15. Available from URL: http://www.health.qld.gov.au/hrpolicies/wage_rates/nursing.asp.
  16. Queensland Health. Medical officers’ base pay rates – queensland health 2010.
  17. Available from URL: http://www.health.qld.gov.au/medical/docs/payrates_2010.pdf.
  18. C. D’ Apuzzo Intossicazione alcolica acuta e fluidi Alcol – Evidence-based medicine, Fluidi, Tossicologia 14 dicembre 2012. https://www.empillsblog.com/intossicazione-alcolica-acuta-e-fluidi/.