PDF | A shortened item scale for clinical quantitation of the severity of the Assessment of Alcohol Withdrawal: The Revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) Download full-text PDF. The Clinical Institute Withdrawal Assessment for Alcohol–Revised (CIWA-Ar) protocol (Figure 1) is the most common method of treating alcohol withdrawal in our institution and it is. Background: Alcohol withdrawal protocols involving symptom-triggered administration of Key words: alcohol withdrawal protocol; Clinical Institute Withdrawal.
|Language:||English, Spanish, French|
|Genre:||Politics & Laws|
|ePub File Size:||16.58 MB|
|PDF File Size:||14.33 MB|
|Distribution:||Free* [*Sign up for free]|
TACTILE DISTURBANCES -- Ask "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under. Alcohol Withdrawal Assessment Scoring Guidelines (CIWA - Ar). Nausea/ Vomiting - Rate on scale 0 - 7. Tremors - have patient extend arms & spread fingers. of Alcohol Scale, Revised (CIWA – Ar). Many qualification instruments have been developed for monitoring alcohol withdrawal. (Guthrie, ; Sullivan et al.
Description: The CIWA-AD, based on DSM-III-R, is an 8-item scale designed to allow clinicians to quantify the current severity of alcohol withdrawal in clinical and research settings in which detection of alcohol withdrawal is important and in which the severity of withdrawal symptoms needs to be closely monitored. It can be repeated as often as necessary to measure progression of withdrawal. It is a reliable, brief, uncomplicated, and clinically useful scale that can also be used to monitor response to treatment. This scale offers an increase in efficiency over the original CIWA-A scale, while retaining clinical usefulness, validity, and reliability. It can be incorporated into the usual clinical care of patients undergoing alcohol withdrawal and into clinical drug trials of alcohol withdrawal.
This reveals the lack of consensus between existing scales as to which symptoms constitute the most significant indicators of the alcohol-withdrawal syndrome.
No single symptom was included in all the scales analysed and scales differed in the numbers of items included.
A total of 30 symptoms and signs were described. Anxiety was included in most scales McGrath, ; Bjorkqvist et al. Loss of co-ordination one scale: Bjorkqvist et al. Blood pressure, pulse and temperature were often measured as part of the overall assessment, but were included in only five scales Gross et al.
Scales 1—8 did not specify scoring criteria in the paper, whereas scales 9—16 did. Table 2 illustrates the wide variations in the weightings given to different symptom groups by the rating scales.
Figures given are the percentage contribution of each group of symptoms to the total scale scores. The seven groupings were those of affect, gastrointestinal GI disturbance, autonomic nervous system ANS disturbance, neurological disturbance, sleep, psychotic features and seizures. This comparison emphasizes the disparity in the weighting of items in the scales. Reasons for the particular make-up of the scales concerned were not published in the original descriptions.
Some of the scales appear to be biased towards the known actions of the drugs under investigation. For example the scale which gives the highest weighting to autonomic symptoms, such as hypertension and raised pulse rate Scale 11, Kraus et al.
The scale that gave the highest weighting to seizures was used in investigating carbamazepine Agricola et al. The most widely used scales, and those from which several other scales have been derived, are the Total Severity Assessment Gross et al.
Both are well validated and will now be described in more detail.
Gross et al. These varied from those that simply recorded the presence or absence of symptoms, to those that rated severity. The scale contains 30 variables which are rated on an 8-point scale. Zero indicates the absence of a symptom, whilst 7 indicates the maximum severity. The item scale was intended as a research tool and a shorter item scale, the SSA, was produced for clinical use. Correlation coefficients were then calculated.
Of the 30 items, eight, including three SSA items, were not evaluated. Six of the 22 items rated including two SSA did not show statistically significant correlation between the two assessors' scores. This left only 16 of the 30 items in the TSA six of 11 SSA with statistically significant correlations, suggesting that they might be reliable measures of withdrawal severity.
Subsequent trials revealed the TSA to be valid when compared to global rating scales, but the extensive training of evaluators required to achieve reliability limited widespread use. This resulted in a item scale, which retained just seven of the 11 SSA items. Inter-rater reliability was demonstrated by comparing assessments made by seven trained nurses on three video cases.
Validity was considered by comparison of scores on CIWA rated by nurses, with a 3-point global rating of severity of withdrawal made by a physician at the initial assessment Shaw, Further trials have shown a modified CIWA to minimize under- and over-dosing with benzodiazepines in the treatment of alcohol withdrawal. This scale takes only 1 min to complete by assessors with experience in its application, but a further development, an 8-item scale, the CIWA-AD, requires training to ensure adequate reliability Sellers et al.
Although the time taken to administer these rating scales may be of limited relevance in a research setting, it is often one factor limiting widespread clinical use.
Metcalfe et al. This scale used fewer objective criteria, in an attempt to improve ease of use.
More recently, Wetterling et al. The authors claim that the AWS allows rational therapy by predicting those who are at greater risk of complicated withdrawal. Such research will add substantially to current knowledge only if a valid, reliable rating scale is used. Such a rating scale will also enable clinicians to manage alcohol withdrawal more effectively, as they are able to assess severity and progress in a more defined way.
This paper has reviewed published scales which have been used in the management of acute alcohol withdrawal. In most of the articles describing these scales, the primary objective was an assessment of treatment modalities and not the development of a rating scale. As a result, few of the scales have been subjected to a rigorous assessment of validity and reliability and few authors have attempted to justify their reasons for including the individual components of the scale.
The weighting of scores often seems to favour symptoms likely to respond significantly to the medication under investigation. This program to improve recognition and treatment of alcohol withdrawal was conducted because of a lack of validated diagnostic and clinical monitoring tools that could guide and improve treatment.
Do you know of cases when it has been applied, interpreted, or used inappropriately? There are some very good YouTube videos that are useful for training, such as this one.
Almost 30 years after we published this paper, I still get approached about its implementation. The most common misinterpretation of the CIWA-Ar Score is that it is a recipe for when to use pharmacologic treatment.
While scores of 10 or less rarely need pharmacologic treatment, clinical judgement is still very important with scores between Our typical management has been to use diazepam loading Sellers With training, nursing staff can readily and reliably perform scoring, but the score should not be used to drive "standing orders".
Are there any adjustments or updates you would make to the score based on new data or practice changes? We did not emphasize the importance of standardized training of all staff and the usefulness of the assessment of within and between rater reliability in the paper.
Patients or standardized trained patients can be used to ensure good staff agreements on ratings.