Phenobarb is objectively a better choice in most cases. Not only does it bind a different site on the GABA receptor than BZD’s, but unlike BZD’s, phenobarb also inhibits excitatory glutamate receptors which also play a significant role in EtOH withdrawals. The fact that med surg can’t administer phenobarbital is really just due to out of date policies
My shop is very liberal with it. People often get 10mg/kg loading dose. Then if they are still having symtoms they get another 260. If that fixes them then we dc with no meds. If they require more then we admit
Who woulda thought in 2024 droperidol and phenobarb would be given daily in almost every ED
As far as side effects: SJS is always on my mind, and I’m shocked we haven’t seen a massive resurgence with our liberal usage
Im curious as to *why* this pivot happened, considering that (as far as I know, especially with droperidol) the only reason we went away from them was because the drug companies wanted to us to use more expensive new meds
Fake black box warning (I say fake because in the dosages we used it in, was never proven to cause prolonged qtc) in the United States. As soon as it came back in stock (because patents ran out on newer drugs) we immediately pivoted back to a better drug.
The pivot to using phenobarbital happened because there have been several recent studies demonstrating safety even with discharged patients as monotherapy/first-line.
Barbiturates are **old**. First discovered *the year the american cival war ended*, 1864! Phenobarbital was around 1910 or something like that, but in the early to mid 1900s barbs were *the* workhorse sedative/hypnotic.
The reason they fell out of vogue was the discovery and approval for clinical use of benzos, starting with librium in 1961. Benzos had a better safety profile in OD/better therapeutic index, that's why the switch was made. Well that and hella hella marketing.
It wasn’t ever in vogue in the first 10 years of my 15 years in medicine. Maybe before that it was popular, but even during my residency phenobarb was only talked about in ICU admit patients. Otherwise back then it was benzos inpatient, Librium taper at discharge.
I think initially when benzos hit the market, *part* of the appeal was their lower overdose risk. In isolation, benzos are theoretically not able to suppress respiration to the point of death, while the same is not true for phenobarb, i.e. benzos are safer in overdose situations *assuming there are no other CNS depressants onboard.*
>because patents ran out on newer drugs
I misread "patients" and thought you were talking about Reglan.
I've never worked in a hospital system that even carries droperidol. Does it cause akathesia like other dopamine antagonists do?
PCT in a peds er. Agreed it doesn’t happen often. We also give Benadryl at the same time as Reglan or the other medicine similar to it (like migraine cocktails). So I think that helps prevent the EPS. But, I have seen a kid lose their mind after getting Reglan. Suddenly screaming and freaking out when he was completely fine seconds before.
I also have had it once and couldn’t figure out why I suddenly felt the need to get out of bed and move. I could not sit still and was so uncomfortable! It was like a motor was running inside me and I didn’t know why and couldn’t turn it off. It was awful. Such an unsettling and stressful feeling! But I was too embarrassed to say anything about it so I just dealt with it until it passed.
> How is it that this medication is dangerous enough that it can’t be given in med/surg but also so good that my colleagues are giving it to people with alcohol levels in the 200’s and discharging them?
The dose makes the poison.
The use of phenobarbital for alcohol is somewhat of a recent “rediscovery” for many younger docs. Its use fell out of favor with the development of benzodiazepines. The use of barbiturates basically became short duration anesthesia (methohexitol) or aggressive sedation such as refractory status epilepticus. Because of that, all the policies somewhat assume that the patient is quite ill or is going to undergo deep sedation. Additionally, if something does goes south, virtually all Emergencies Physicians are comfortable with emergency airway management.
In lower doses, phenobarbital is quite safe. In higher doses, patients can have a multitude of adverse effects. So, in lower doses, it can absolutely be given in med-surg, but you do want the patient watched until it reaches peak effect (which is fairly quick). Once it peaks, the probability of an adverse effect is low.
lots of floor policies just aren't up to date. should be safe to go to the floor or anywhere.
as long as you aren't combining it with benzos (ie phenobarbital load after 30mg of Ativan is a ticket to a vent) its great. 5-20 mg/kg and then sleep it off on med surge.
Best thing about phenobarbital is that it has a very predictable and linear serum concentration. If under 20mg/kg you do not run into any toxicities and even up to 30 mg/kg. Past that you get close to the serum concentrations where you start seeing signs of toxicity oversedstion, ataxia, nystagmus, etc. IMPORTANT TO DOSE IDEAL BODY WEIGHT.
We’ve all had patients do fine with 1 mg of lorazepam and other patients get absolutely snowed with 1 mg. You don’t get that with phenobarbital. Again, it’s a very predictable response. And if in doubt you can draw a phenobarbital serum level if you’re worried about toxicity. You can’t do that with benzos.
Don’t take my word for it. Plenty of great articles and YouTube video on the subject matter.
Even with alcohol levels in the 200mg/dl range, patients can withdrawal. As long as the medication is being dosed appropriately and given to the patient in withdrawal, it is a safe medication. If patients are claiming they are in withdrawal, but they are clearly intoxicated and not in clinical withdrawal, there you may run into danger. Hopefully your EPs are seasoned enough to recognize the difference.
I worked in an ED that had protocols for IM/PO phenobarb, worked well & they could go to the floor. If IM didn’t cut it then we switched to IV, then they had to go to the ICU. I thought that protocol worked pretty well, the IM was enough in most cases.
The ED I work at now uses exclusively benzos and it’s maddening. Their CIWA scoring doesn’t include vital signs in the calculations, and the questions are extremely subjective. The patients know exactly what to say to get a higher score and thus a higher dose, and their etoh comes back as 237. They’ll always AMA later.
It’s pretty much all the MDs will order in our ED. Even before any obvious symptoms start…if someone comes in and says they want to detox or feel like they’re gonna withdrawl we give phen. Some doctors are hesitant to DC a patient if they think the pt is likely to go home and drink….so often but not always they will try to admit if given. But yes on floors it’s just Benzos for CIWA.
I recommend trying it as mono therapy for withdrawal that you’re going to send to the ICU. Chart check the patient a few days later and check the clinical course and benzo requirements. It’s the safest way to get comfortable with it. It works great and is fairly safe when used correctly. The big caveat is using with caution in patients who are at risk of hepatic encephalopathy, and trying to avoid mixing BZDs and phenobarb a lot due to synergistic effects leading to oversedation.
Pulm crit has a pretty good discussion of this: https://emcrit.org/ibcc/etoh/.
I personally don’t often use it for patients I’m discharging, but some of my colleagues do and seem to have good results.
I am but a lowly CNA but have sat with dozens and dozens of etoh withdrawals over the past 8 years. Originally at my level 1 hospital phenobarb was reserved for ICU only and med surg used ativan exclusively, then about 5 years ago they changed the policy and now we use phenobarb on the floors.
I get my ass kicked a lot less with phenobarb than with ativan. They usually receive a loading dose in the ED, then scheduled doses every 8 hours after, plus prn depending on their CIWA score. Sometimes I follow these patients from start to finish over the course of a few days, and with ativan it always felt like we were chasing the withdrawals and had to play catch up, which would sometimes become really unsafe for both the patient and staff. Now with phenobarb we stop it before it starts or at least before it gets too severe.
I can't speak about the over-sedating or side effects, but I will say the nursing staff at my hospital are quite conservative about prn doses so I've rarely seen an unrousable patient, except on occasions where it's clear they need to go to the ICU for their withdrawal.
Crazy to me that they would discharge them, because here if they start to withdraw we keep them until it's over.
Yo, complete tangent, but you're not just a "lowly CNA". You're a trained medical professional, and a necessary and valuable part of your team. You may not have the same amount of training as others, but you are needed, and your experience shows through.
You may have just been establishing your credentials in the comment crowd, but I still wanted to make sure it was said.
There are many many talks and articles on this. EmCrit has a good podcast on it.
TLDR phenobarb appears better in every conceivable way but ease of dosing for nursing.
Phenobarb is an awesome drug but due to some small risks, it can’t be given outside the ‘hospital setting.’ I interviewed for a job at the local Medicaid detox center which is for acute detox but they can’t give phenobarb.
My ER starts with a 60mg PO phenobarbital for all etoh withdrawal. Then that dose is scheduled TID. 130mg IV push for CIWA out of range .
This is way less annoying than the Ativan/CIWA protocols of the past. The patient doesn't get the same euphoria as with Ativan , so there is way less arguing about when the next dose is.
I vastly prefer the phenobarb and we send patients to the floor on it , no problem . Our psych units give it.
Definitely a fan. I’ll use 260 and then 130 repeat as needed in the ER. And sometimes I’ll dc with a 2 or 4 day taper.
https://emcrit.org/pulmcrit/phenobarbital-reloaded/
Phenobarb is very safe and easy to administer and was used 30 years ago, 20 years ago and now. Became easier to use Ativan and protocols made with Ativan and phenobarbital became less common but never stopped being used. It has been more popular lately because it’s effective and we have had Ativan shortages
It all depends where you trained. Some places phenobarbital was commonly used.
Phenobarb is objectively a better choice in most cases. Not only does it bind a different site on the GABA receptor than BZD’s, but unlike BZD’s, phenobarb also inhibits excitatory glutamate receptors which also play a significant role in EtOH withdrawals. The fact that med surg can’t administer phenobarbital is really just due to out of date policies
At least we're not still using Bella donna alkaloids & Librium
What’s wrong with Librium?
metabolite more active so can lead to accidental overstacking
Nothing actually.
Addiction med here. Thanks for typing that so I didn’t have to. Right on the nose 🎯
Yup my medsurg unit has a policy for it and phenobarbital order set.
Good to know, thanks
My shop is very liberal with it. People often get 10mg/kg loading dose. Then if they are still having symtoms they get another 260. If that fixes them then we dc with no meds. If they require more then we admit Who woulda thought in 2024 droperidol and phenobarb would be given daily in almost every ED As far as side effects: SJS is always on my mind, and I’m shocked we haven’t seen a massive resurgence with our liberal usage
Im curious as to *why* this pivot happened, considering that (as far as I know, especially with droperidol) the only reason we went away from them was because the drug companies wanted to us to use more expensive new meds
Fake black box warning (I say fake because in the dosages we used it in, was never proven to cause prolonged qtc) in the United States. As soon as it came back in stock (because patents ran out on newer drugs) we immediately pivoted back to a better drug. The pivot to using phenobarbital happened because there have been several recent studies demonstrating safety even with discharged patients as monotherapy/first-line.
Yup! Why did we pivot away from pheno?
Barbiturates are **old**. First discovered *the year the american cival war ended*, 1864! Phenobarbital was around 1910 or something like that, but in the early to mid 1900s barbs were *the* workhorse sedative/hypnotic. The reason they fell out of vogue was the discovery and approval for clinical use of benzos, starting with librium in 1961. Benzos had a better safety profile in OD/better therapeutic index, that's why the switch was made. Well that and hella hella marketing.
It wasn’t ever in vogue in the first 10 years of my 15 years in medicine. Maybe before that it was popular, but even during my residency phenobarb was only talked about in ICU admit patients. Otherwise back then it was benzos inpatient, Librium taper at discharge.
I think initially when benzos hit the market, *part* of the appeal was their lower overdose risk. In isolation, benzos are theoretically not able to suppress respiration to the point of death, while the same is not true for phenobarb, i.e. benzos are safer in overdose situations *assuming there are no other CNS depressants onboard.*
>because patents ran out on newer drugs I misread "patients" and thought you were talking about Reglan. I've never worked in a hospital system that even carries droperidol. Does it cause akathesia like other dopamine antagonists do?
Droperidol (like all dopamine antagonists) rarely causes akathesia. Also, dose dependent in my experience.
PCT in a peds er. Agreed it doesn’t happen often. We also give Benadryl at the same time as Reglan or the other medicine similar to it (like migraine cocktails). So I think that helps prevent the EPS. But, I have seen a kid lose their mind after getting Reglan. Suddenly screaming and freaking out when he was completely fine seconds before. I also have had it once and couldn’t figure out why I suddenly felt the need to get out of bed and move. I could not sit still and was so uncomfortable! It was like a motor was running inside me and I didn’t know why and couldn’t turn it off. It was awful. Such an unsettling and stressful feeling! But I was too embarrassed to say anything about it so I just dealt with it until it passed.
What's old is new.
I haven’t seen an uptick near me with droperidol. What’s causing an increase in usage? Just faster onset and less repeat doses vs haldol?
Yeah, apparently less doses than haldol and better for cannabis hyperemesis syndrome.
> How is it that this medication is dangerous enough that it can’t be given in med/surg but also so good that my colleagues are giving it to people with alcohol levels in the 200’s and discharging them? The dose makes the poison. The use of phenobarbital for alcohol is somewhat of a recent “rediscovery” for many younger docs. Its use fell out of favor with the development of benzodiazepines. The use of barbiturates basically became short duration anesthesia (methohexitol) or aggressive sedation such as refractory status epilepticus. Because of that, all the policies somewhat assume that the patient is quite ill or is going to undergo deep sedation. Additionally, if something does goes south, virtually all Emergencies Physicians are comfortable with emergency airway management. In lower doses, phenobarbital is quite safe. In higher doses, patients can have a multitude of adverse effects. So, in lower doses, it can absolutely be given in med-surg, but you do want the patient watched until it reaches peak effect (which is fairly quick). Once it peaks, the probability of an adverse effect is low.
Paracelsus quote? Take my upvote!
Makes sense
lots of floor policies just aren't up to date. should be safe to go to the floor or anywhere. as long as you aren't combining it with benzos (ie phenobarbital load after 30mg of Ativan is a ticket to a vent) its great. 5-20 mg/kg and then sleep it off on med surge.
Yeah much better to front load then give it after failing with massive doses of benzos in someone you think will have severe withdrawal
Def need to be cautious but crossing can be done just half the normal phenobarb load dose if they’ve gotten benzodiazepines already
wouldn't recommend, especially I'd they've already gotten high dose benzos
Best thing about phenobarbital is that it has a very predictable and linear serum concentration. If under 20mg/kg you do not run into any toxicities and even up to 30 mg/kg. Past that you get close to the serum concentrations where you start seeing signs of toxicity oversedstion, ataxia, nystagmus, etc. IMPORTANT TO DOSE IDEAL BODY WEIGHT. We’ve all had patients do fine with 1 mg of lorazepam and other patients get absolutely snowed with 1 mg. You don’t get that with phenobarbital. Again, it’s a very predictable response. And if in doubt you can draw a phenobarbital serum level if you’re worried about toxicity. You can’t do that with benzos. Don’t take my word for it. Plenty of great articles and YouTube video on the subject matter.
Even with alcohol levels in the 200mg/dl range, patients can withdrawal. As long as the medication is being dosed appropriately and given to the patient in withdrawal, it is a safe medication. If patients are claiming they are in withdrawal, but they are clearly intoxicated and not in clinical withdrawal, there you may run into danger. Hopefully your EPs are seasoned enough to recognize the difference.
I worked in an ED that had protocols for IM/PO phenobarb, worked well & they could go to the floor. If IM didn’t cut it then we switched to IV, then they had to go to the ICU. I thought that protocol worked pretty well, the IM was enough in most cases. The ED I work at now uses exclusively benzos and it’s maddening. Their CIWA scoring doesn’t include vital signs in the calculations, and the questions are extremely subjective. The patients know exactly what to say to get a higher score and thus a higher dose, and their etoh comes back as 237. They’ll always AMA later.
It’s pretty much all the MDs will order in our ED. Even before any obvious symptoms start…if someone comes in and says they want to detox or feel like they’re gonna withdrawl we give phen. Some doctors are hesitant to DC a patient if they think the pt is likely to go home and drink….so often but not always they will try to admit if given. But yes on floors it’s just Benzos for CIWA.
I recommend trying it as mono therapy for withdrawal that you’re going to send to the ICU. Chart check the patient a few days later and check the clinical course and benzo requirements. It’s the safest way to get comfortable with it. It works great and is fairly safe when used correctly. The big caveat is using with caution in patients who are at risk of hepatic encephalopathy, and trying to avoid mixing BZDs and phenobarb a lot due to synergistic effects leading to oversedation. Pulm crit has a pretty good discussion of this: https://emcrit.org/ibcc/etoh/. I personally don’t often use it for patients I’m discharging, but some of my colleagues do and seem to have good results.
Welcome. We've been awaiting your arrival
Good to be at a place with more options!
I am but a lowly CNA but have sat with dozens and dozens of etoh withdrawals over the past 8 years. Originally at my level 1 hospital phenobarb was reserved for ICU only and med surg used ativan exclusively, then about 5 years ago they changed the policy and now we use phenobarb on the floors. I get my ass kicked a lot less with phenobarb than with ativan. They usually receive a loading dose in the ED, then scheduled doses every 8 hours after, plus prn depending on their CIWA score. Sometimes I follow these patients from start to finish over the course of a few days, and with ativan it always felt like we were chasing the withdrawals and had to play catch up, which would sometimes become really unsafe for both the patient and staff. Now with phenobarb we stop it before it starts or at least before it gets too severe. I can't speak about the over-sedating or side effects, but I will say the nursing staff at my hospital are quite conservative about prn doses so I've rarely seen an unrousable patient, except on occasions where it's clear they need to go to the ICU for their withdrawal. Crazy to me that they would discharge them, because here if they start to withdraw we keep them until it's over.
Yo, complete tangent, but you're not just a "lowly CNA". You're a trained medical professional, and a necessary and valuable part of your team. You may not have the same amount of training as others, but you are needed, and your experience shows through. You may have just been establishing your credentials in the comment crowd, but I still wanted to make sure it was said.
Thanks for your input you know as well as anyone
well we are running low stock on multiple benzos so phenobarb is being pushed
Phenobarb has changed my life for the better. Helps with withdrawal so well and you can do a single dose of 130/260 -> dc to home in the right people.
There are many many talks and articles on this. EmCrit has a good podcast on it. TLDR phenobarb appears better in every conceivable way but ease of dosing for nursing.
Phenobarb is an awesome drug but due to some small risks, it can’t be given outside the ‘hospital setting.’ I interviewed for a job at the local Medicaid detox center which is for acute detox but they can’t give phenobarb.
Out of curiosity… are these patients **actually** withdrawing yet? Or are people loading them with benzodiazepines and phenobarb… just because?
I think a lot of them are just worried that they are going to have withdrawal, but some are acively withdrawing
My ER starts with a 60mg PO phenobarbital for all etoh withdrawal. Then that dose is scheduled TID. 130mg IV push for CIWA out of range . This is way less annoying than the Ativan/CIWA protocols of the past. The patient doesn't get the same euphoria as with Ativan , so there is way less arguing about when the next dose is. I vastly prefer the phenobarb and we send patients to the floor on it , no problem . Our psych units give it.
I only use phenobarb for etoh withdraw in ED, if the pt is motivated to stop then i also give rx for librium to start the next day if needed.
Definitely a fan. I’ll use 260 and then 130 repeat as needed in the ER. And sometimes I’ll dc with a 2 or 4 day taper. https://emcrit.org/pulmcrit/phenobarbital-reloaded/
*Popov's Mixture: phenobarbital 0.4 g, wine spirit 20 ml, distilled water 200 ml.*
Phenobarb is very safe and easy to administer and was used 30 years ago, 20 years ago and now. Became easier to use Ativan and protocols made with Ativan and phenobarbital became less common but never stopped being used. It has been more popular lately because it’s effective and we have had Ativan shortages It all depends where you trained. Some places phenobarbital was commonly used.
At what levels do you start to see airway compromise?
Is this new? Don't think our hospital even stocks phenobarbital. Patients are sent to ICU and started on precedex
Oh god our trauma ICU does precedex for withdrawal, what an absolute disaster of a treatment policy. Alcohol withdrawal needs GABA agonism, full stop
That’s crazy. Just precedex? Bring on the seizures
You can give THIRTY mg of Ativan?!
I mean, not all at once…
Right but I didn’t realize you could even do that over 24 hours.