High-dose Phenobarbital for Severe Alcohol Withdrawal in the Emergency Department

Purpose Alcohol withdrawal syndrome (AWS) frequently requires pharmacologic intervention in the Emergency Department (ED). Phenobarbital and benzodiazepines are both used in managing AWS, with phenobarbital showing a more predictable response in some patients. Phenobarbital affects both GABA and glutamate receptors, making it a prominent treatment option for severe AWS despite guidelines favoring benzodiazepines. This study evaluated whether high-dose intravenous phenobarbital affects intensive care unit (ICU) admission rates compared to standard treatment in severe alcohol withdrawal. Methods This retrospective study reviewed records of patients with severe alcohol withdrawal (CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, Revised) score ≥15) in the ED from February 2022 to August 2023. Primary outcome was ICU admission rate from the ED. Secondary outcomes included ICU length of stay (LOS), hospital admission rate, mechanical ventilation rate, 7-day readmission rate, hospital mortality, total benzodiazepine dose, and discharge against medical advice rate. Results Out of 171 patients, the high-dose phenobarbital group had a significantly higher median CIWA-Ar score (23 vs. 19, p < 0.001). There was no significant difference in ICU admissions (10.3% vs. 8.3%, p = 0.749). The high-dose group had shorter ICU LOS (24 hours vs. 63 hours, p = 0.006) and used less benzodiazepines (2 mg vs. 8 mg, p = 0.007). Conclusion High-dose phenobarbital is effective in managing severe AWS, reducing ICU LOS and benzodiazepine use.