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LA PSIQUIATRIA DE ENLACE Y EL DIAGNOSTICO DEL DELIRIUM TREMENS
(especial para SIIC © Derechos reservados)
La manifestación clínica más grave y potencialmente fatal de la abstinencia de alcohol es el delirium tremens, cuadro observado en aproximadamente el 5% al 10% de los pacientes con trastorno por consumo de alcohol que requieren hospitalización.
Autor:
Subho Chakrabarti
Columnista Experta de SIIC

Institución:
Department of Psychiatry, Postgraduate Institution of Medical Education and Research (PGIMER), Chand


Artículos publicados por Subho Chakrabarti
Coautor
Abhishek Ghosh* 
Medico, Department of Psychiatry, Postgraduate Institution of Medical Education and Research (PGIMER), Chandigarh, India, Chandigarh, India*
Recepción del artículo
19 de Abril, 2016
Aprobación
25 de Noviembre, 2016
Primera edición
20 de Diciembre, 2016
Segunda edición, ampliada y corregida
22 de Noviembre, 2017

Resumen
La manifestación clínica más grave y potencialmente fatal de la abstinencia de alcohol es el delirium tremens (DT), cuadro observado en aproximadamente el 5% al 10% de los pacientes con trastorno por consumo de alcohol que requieren hospitalización. El diagnóstico adecuado del DT requiere conocer los factores de riesgo, el cuadro clínico típico y la evolución y la gravedad de los síntomas de abstinencia. Las benzodiazepinas son el tratamiento farmacológico de elección para los pacientes con DT. Su eficacia fue confirmada mediante numerosos estudios. Si bien hay drogas alternativas que también pueden ser efectivas, las benzodiazepinas son elegidas debido a su perfil farmacocinético y de seguridad favorable. Las drogas alternativas son utilizadas como complemento de las benzodiazepinas para el tratamiento de los pacientes con cuadros de abstinencia complicados o resistentes. Los esquemas que incluyen dosis de carga administradas por vía oral o intravenosa son los preferidos para los pacientes con DT. El aumento rápido de la dosis de benzodiazepinas de acuerdo con la gravedad de los síntomas evaluados mediante escalas estructuradas y el empleo de drogas adyuvantes alternativas permiten el control oportuno del DT. Cerca del 10% de los pacientes que presentan resistencia a las benzodiazepinas requieren tratamiento en unidades de terapia intensiva con dosis intravenosas elevadas de benzodiazepinas y otras drogas, evaluación minuciosa y, de ser necesario, ventilación mecánica. La suplementación vitamínica y la atención adecuada por parte del personal de enfermería también son componentes esenciales del tratamiento. Los psiquiatras de enlace deberían integrar equipos multidisciplinarios destinados al tratamiento agudo de los pacientes con DT. No obstante, solo los psiquiatras de enlace con capacidades y conocimiento que se desempeñan de acuerdo con los protocolos estandarizados pueden lograr que determinados pacientes con DT reciban tratamiento adecuado. El psiquiatra de enlace también debe procurar un periodo de abstinencia seguro que proteja la dignidad del paciente y lo prepare para resolver la dependencia.

Palabras clave
abstinencia de alcohol, delirium tremens, tratamiento, medicamentos, benzopiazepinas


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Abstract
The most serious and potentially life-threatening manifestation of alcohol withdrawal is delirium tremens (DT) or alcohol withdrawal delirium, which occurs in about 5% to 10% of hospitalized patients with alcohol problems. A consideration of risk factors, the typical clinical picture, evolution of withdrawal-symptoms and their severity aid in the proper recognition of DT. Benzodiazepines are the mainstay of medication treatment of DT. Their efficacy has been established by a large body of evidence. Although alternative medications might be equally effective, benzodiazepines are preferred because of their favourable pharmacokinetic and safety. Alternative medications are used as adjuncts to benzodiazepines in the treatment of complicated and refractory withdrawal states. Oral or intravenous loading-dose regimens are preferred for treatment of DT. Rapidly escalating doses of benzodiazepines titrated to symptom-severity on structured scales and the use of adjunctive alternative medications ensures prompt control of DT. About 10% of patients who are benzodiazepine-resistant require treatment in intensive care units with massive intravenous doses of benzodiazepines and additional medications, careful monitoring and mechanical ventilation if necessary. Vitamin supplementation and adequate medical, nursing and supportive care are other essential components of management. Liaison psychiatrists are expected to form an integral part of the multidisciplinary team, which manages patients with DT in acute-care settings. Only skilled and knowledgeable liaison psychiatrists relying on standardized treatment protocols can make certain that patients with DT receive adequate care. The liaison psychiatrist also needs to ensure a safe and humane withdrawal that protects the patient's dignity and prepares the patient for on-going treatment of dependence.

Key words
alcohol withdrawal, delirium tremens, treatment, medications, benzodiazepines


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Especialidades
Principal: Cuidados IntensivosSalud Mental
  Relacionadas: EnfermeríaMedicina Interna

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Subho Chakrabarti, 160012, Sector 12, Chandigarh, India
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