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The Rational Clinical Examination
August 28, 2018

Will This Hospitalized Patient Develop Severe Alcohol Withdrawal Syndrome?The Rational Clinical Examination Systematic Review

Author Affiliations
  • 1British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
  • 2Faculty of Medicine, University of British Columbia, Vancouver, Canada
  • 3Bond University, Robina, Queensland, Australia
JAMA. 2018;320(8):825-833. doi:10.1001/jama.2018.10574
Key Points

Question  Severe alcohol withdrawal syndrome (SAWS) can have devastating consequences, but how to predict which patients will be affected in acute care settings is not clear.

Findings  Individual symptoms and signs are not useful for predicting SAWS. Assessment tools incorporating combinations of symptoms and signs better predict which patients are at high risk of SAWS.

Meaning  The most effective method for predicting SAWS in acute care settings is use of a risk assessment tool that combines findings from a patient’s history and clinical examination.


Importance  Although severe alcohol withdrawal syndrome (SAWS) is associated with substantial morbidity and mortality, most at-risk patients will not develop this syndrome. Predicting its occurrence is important because the mortality rate is high when untreated.

Objective  To assess the accuracy and predictive value of symptoms and signs for identifying hospitalized patients at risk of SAWS, defined as delirium tremens, withdrawal seizure, or clinically diagnosed severe withdrawal.

Data Sources  MEDLINE and EMBASE (1946-January 2018) were searched for articles investigating symptoms and signs predictive of SAWS in adults. Reference lists of retrieved articles were also searched.

Study Selection  Original studies that were included compared symptoms, signs, and risk assessment tools among patients who developed SAWS and patients who did not.

Data Extraction and Synthesis  Data were extracted and used to calculate likelihood ratios (LRs), sensitivity, and specificity. A meta-analysis was performed to calculate summary LR.

Results  Of 530 identified studies, 14 high-quality studies that included 71 295 patients and 1355 relevant cases of SAWS (1051 cases), seizure (53 cases), or delirium tremens (251 cases) were analyzed. A history of delirium tremens (LR, 2.9 [95% CI 1.7-5.2]) and baseline systolic blood pressure 140 mm Hg or higher (LR, 1.7 [95% CI, 1.3-2.3) were associated with an increased likelihood of SAWS. No single symptom or sign was associated with exclusion of SAWS. Six high-quality studies evaluated combinations of clinical findings and were useful for identifying patients in acute care facilities at high risk of developing SAWS. Of these combinations, the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) was most useful, with an LR of 174 (95% CI, 43-696; specificity, 0.93) when patients had 4 or more individual findings and an LR of 0.07 (95% CI, 0.02-0.26; sensitivity, 0.99) when there were 3 or fewer findings.

Conclusions and Relevance  Assessment tools that use a combination of symptoms and signs are useful for identifying patients at risk of developing severe alcohol withdrawal syndrome. Most studies of these tools were not fully validated, limiting their generalizability.

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