Intravenous Fluids and Alcohol Intoxication

01 May
May 1, 2014
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Intravenous Fluids and Alcohol IntoxicationFrequently, patients with acute alcohol intoxication are brought to the emergency department (ED) for evaluation and treatment.  Although practice patterns vary, it is not an uncommon practice to give normal saline to these patients in the hopes that the saline will cause a dilution effect on the level of alcohol helping patients sober faster and therefore having a shorter length of stay in the ED.  At the end of 2013 a study was published evaluating intravenous fluids and alcohol intoxication.

How often do physicians use intravenous fluids in alcohol intoxication? (22134421) (9950378)

  • 73 – 87% of US emergency medicine physicians use intravenous fluids to treat alcohol intoxication

Are there any studies looking at the benefit of intravenous fluids and alcohol intoxication?

(1940231) (9950378)

Author and Year
Number of Patients
Study Type
Outcomes
Results
Gershmann (1991)103ObservationalEthanol ClearanceNo Difference
Troups et al (1992)19ObservationalEthanol ClearanceNo Difference
Li et al (1999)10CrossoverEthanol ClearanceNo Difference

Table Modified from Best BETs

What is the most recent study evaluating the benefit of intravenous fluids and alcohol intoxication? (24308613)

What they did:

  • Single-blind, randomized controlled trial of 144 uncomplicated acutely intoxicated ED patients aged 18 – 50 years of age
  • Carried out in 2 EDs in Queensland, Australia
  • Single bolus of 20mL/kg intravenous 0.9% saline + observation vs observation alone
  • Uncomplicated patients = no injuries, overdose, or psychiatric conditions requiring ongoing treatment

Primary Outcomes:

  • ED Length of Stay (EDLOS) = Triage time to actual discharge time

Secondary Outcomes:

  • Treatment Time = Time from being assessed by a treating doctor or nurse, until the time patient deemed ready for discharge
  • Breath Alcohol Levels
  • Intoxication Symptom Score
  • Level of Intoxication
  • Associated Healthcare Costs

Results:

  • Baseline blood alcohol content (BAC) in two groups: 0.2% vs 0.19%
  • Baseline Intoxication Symptoms Scores: 22.0 vs 22.3
  • EDLOS: 287 vs 274 minutes (p value = 0.89)
  • Treatment Time: 244 vs 232 minutes (p value = 0.94)
  • Absolute Difference in Breath Alcohol Level at 2 Hours: -0.036 vs -0.013 (p value = 0.16)
  • Intoxication Score and Level of Intoxication were not significantly different between the two groups
  • Cost Savings $156.44 in the intravenous fluids group and $124.52 in the observation group resulting in a net $31.92 saved per patient with no intravenous fluids

Limitations:

  • No placebo in the observation group
  • Staff and patients not blinded
  • When ED volume was high, many intoxicated patients were not enrolled into study (i.e. 82 patients)
  • Not powered for secondary outcomes (i.e. Although the absolute breath alcohol level was decreased at 2 hours, because of the small numbers enrolled in this study…not statistically significant)

Conclusion: Intravenous normal saline plus observation does not decrease ED length of stay compared with observation alone in uncomplicated, alcohol intoxicated patients

Alcohol Intoxication

Take Home Message

There is no evidence that intravenous fluids will expedite sobriety in patients with acute alcohol intoxication

For more thoughts on intravenous fluids and alcohol intoxication also checkout:

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Salim Rezaie

Clinical Assistant Professor of EM and IM at University of Texas Health Science Center at San Antonio (UTHSCSA)
Creator & Founder of R.E.B.E.L. EM

Latest posts by Salim Rezaie (see all)

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10 replies
  1. Anand Senthi says:

    As you point out, this study appears underpowered as a real finding of reduced BAL that was present might have been significant with larger numbers. As a result this study I wouldn’t have thought would be sufficient to change practice

    Reply
    • Salim Rezaie says:

      Hello Anand,
      TY for reading and your question. Although there was a trend to have a decrease in BAL, there was no difference in ED LOS or treatment time regardless. ED LOS was powered and statistically significant. So if there is no decrease in ED LOS and you spend money and time giving IVF, why would you continue that practice? Not to mention the chances of bacteremia and thrombophlebitis from IV placement. So you have a slight decrease in BAL, but no difference in outcomes, would need to see a better study to show me statistical significance before I would start giving IVF for that endpoint. Hope this helps.

      Salim

      Reply
  2. Gregory Roth says:

    EtOH is metabolized as Zero Order kinetics. IVF should not affect the rate.

    Reply
    • Salim Rezaie says:

      Hello Gregory,
      You are absolutely right, however I still see people giving IVF. Invasive (iv), costly (Normal Saline), and no benefit (No decrease in ED LOS). Especially with national shortages of IVF…why do we keep doing this? TY for reading and appreciate your comment.

      Salim

      Reply
  3. Moiz Khan says:

    I think part of the story is a knee jerk reaction to start NS as the first line therapy for every one who visits the ER. This gives us the confidence that we are doing something.
    But I agree with you. After reading the above I will think twice before giving anyone fluids when they come intoxicated in my ER. Thank you for the update!

    Reply
  4. Justin Hensley says:

    At best, 1% of alcohol is excreted in urine. Adding IVF does not increase this, but it might make them have less of a hangover the next morning.
    Sal is lucky to work in San Antonio, one of the world leaders in the concept of “sobering centers”. Maybe with enough effort we can convince the police/EMS that intoxication isn’t always an emergency, and while these people need to be supervised, it doesn’t need to be at the most expensive place in the city.

    Reply
  5. Jennifer C. Trybom says:

    I understand wanting to save money is a definitive goal in healthcare, particularly around ER medicine, and that some patients with acute alcohol intoxication may be simple. However, a good percentage will be people who are suffering from far more complex health issues other than just the identified and obvious. Anyone landing in an ER due to this diagnosis is obviously struggling in some way in their life; from a young teen who’s behavior is a warning sign portending further future suffering, to an older person who’s initial diagnosis hides behind outright, and dangerous, alcohol dependence, with all of its potential and often probable unfortunate health and social outcomes. This later population requires definitive ER interventions and caution, especially when the individual is unconscious and blood alcohol level substantial.

    Reply
    • Salim Rezaie says:

      Jennifer,
      Great point. As you stated in your comment, these are patients that are: uncomplicated, not agitated, and no signs of injury/trauma I am referring to. By no means is this the majority of intoxicated patients, but still there is cost saving here with no worse outcomes. That being said, each patient should be handled in a case by case manner. I always have our social workers and case managers talk to these patients about referrals for outpatient detox, AA, etc….

      TY for reading, and truly appreciate your comment…very important to not forget the social factors leading to the patients presentation to the ER.

      Salim

      Reply

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