EP 192: How Cirrhosis Impacts the Liver

EP 192: How Cirrhosis Impacts the Liver

How Cirrhosis Impacts The Liver

How cirrhosis affects the liver is one of the many interesting medical cases you’ll encounter as a nurse. But what is it? Cirrhosis is a liver disease where liver cells become extremely damaged.

This leads to the damaged cells being replaced with fibrous tissue or scarring of the liver. It also alters the liver’s structure and normal vasculature impairs blood and lymph flow and causes hepatic insufficiency.


Excessive alcohol consumption

  • Too much alcohol intake is the most common cause of cirrhosis


  • Problems with the bile duct: bile stays in the liver and damages cells.
    • Bile duct: carries bile from the liver to the small intestine


  • Different types of hepatitis can cause postnecrotic cirrhosis.

Other diseases

  • Viral Infection, autoimmune 
  • Too much fat collecting in the liver (nonalcoholic)
  • Obesity, hyperlipidemia, diabetics

Right-sided heart failure

  • Hepatic congestion secondary to right-sided heart disease

How the liver works:

  1. The liver takes substances in our blood and metabolizes and detoxifies them. 
  2. Stores and produces substances help digestion, clotting, and immune health. 
  3. When it stops working, every system in our body struggles.

Types of Liver Cells and How They Work

Two main types of cells perform the tasks listed above.

  • Kupffer cells
    • Remove bacteria, debris, parasites, and old RBCs 
  • Hepatocytes
    • Bile production, metabolism, storage, conjugating bilirubin, and detoxification.

Functions of the Liver



  • The excessive amounts will be synthesized and stored as glycogen 
  • The liver can’t synthesize glycogen properly and store it, so more stays in the blood, leading to hyperglycemia
  • Converts glycogen into glucose when blood glucose levels are low to increase sugar levels 
  • If the patient is sick or not eating, the liver is unable to convert the glycogen to glucose so the patient can have episodes of hypoglycemia

Lipids and Proteins: 

  • The liver converts ammonia, which is a byproduct of protein breakdown, into urea which is then excreted via the urine.
  • Urea is much less toxic to the brain than ammonia. 
  • Ammonia = neuro changes + hepatic encephalopathy 


  • Stores vitamins (vitamins B12, A, E, D, and K), minerals, and iron and glycogen. 
  • Remember, bile is essential for the absorption of fat-soluble vitamins. 
  • In cirrhosis, bile production is impaired, which will lead to decreased absorption and storage of those fat-soluble vitamins (vitamins A, D, E, and K)


How cirrhosis affects the body? When epatocytes produce bile to help with the absorption of fats and those fat-soluble vitamins. 

Bile is stored in the gallbladder:

  • In the bile and stool is a substance called bilirubin. 
      • Bilirubin: RBCs are removed by the Kupffer cells, and components of the RBCs are recycled. The Kupffer cells break down the hemoglobin into heme and globin groups.
      • Then hepatocytes metabolize heme into iron and bilirubin. The bilirubin is put into the bile and leaves via the stool (which is why stool is brown because bilirubin is a yellow-brown substance).
  • In cirrhosis, the hepatocytes are damaged and CAN’T do this, so the hepatocytes leak bilirubin in the blood (rather than it entering the bile to leave the body in stool), and the levels increase in the blood and are present in the urine.
    • This is why the patient will be jaundiced and have yellowing of the skin, sclera, mucous membranes, dark urine, along with clay-colored stool.

Production of blood plasma proteins: 

  • Albumin 
    • Maintains oncotic pressure and water regulation within the interstitial tissue,
  • Fibrinogen and prothrombin 
    • Aids in clotting.
Coagulation factors
  • Bleeding within the body activates a complex system of plasma proteins called coagulation factors, which promote blood clot formation. The liver is responsible for producing most of these coagulation factors.
  • Fibrinogen, thrombin = factor II, and factors V, VII, IX X, and XI
  • Protein C, protein S, and antithrombin III


  • Decreases the efficacy of drugs. 
    • In cirrhosis, the patient is very sensitive to drugs because the liver can’t protect them from their harmful effects. It also removes toxins from the body (alcohol) and hormones our glands produce. 
      • Ex: estrogen is metabolized in the liver. However, in cirrhosis, it is unable to metabolize estrogen, which leaves more of the hormone in the body. This can lead to enlarged breast tissue in men (gynecomastia).

Complications of Cirrhosis:

Portal Hypertension

  • The portal vein becomes narrowed due to scar tissue in the liver. This restricts the flow of blood to the liver and increases pressure in the portal vein. This will affect the organs connected to the portal vein.. like the spleen and vessels to the GI structure (varices).

Enlarged spleen

  • “Splenomegaly” What does the spleen do? Stores platelets and WBCs. With portal HTN the platelets and WBCs are kept in the spleen. They can’t leave, and this leads to a low platelet and WBC count.

Esophageal Varices 

  • (as well as gastric varices): due to the increased pressure via the portal vein. This increased pressure causes the veins to become weak, and they can RUPTURE!
  • Life-threatening if the varice ruptures: WHY? Remember the platelet count will be low along with clotting factors available AND levels of Vitamin-K…they are at risk for a total bleed out.

Fluid overload in legs and abdomen

  • Ascites (fluid in the abdomen). If the patient has ascites, they are at risk for infection from bacteria in the GI system. Remember, the immune system is compromised because of low WBC production. Swelling in the legs and ascites is happening due to venous congestion from the portal HTN and low albumin levels (the water is not being regulated in the body and is entering the interstitial tissue).


  • Yellowing of the sclera of the eyes, mucous membranes, and skin. This is due to the hepatocytes leaking bilirubin into the blood rather than the bile.

Hepatic Encephalopathy

  • the liver is unable to detoxify. Ammonia builds up along with other toxins that collect in the brain. This leads to an altered mental system, coma, neuromuscular problems, asterixis (involuntary hand-flapping), hepatic foetor “fetor hepaticus” (late sign; A pungent, musty, sweet smell to the breath)

Clotting problems

  • Thrombocytopenia is seen in most patients with cirrhosis.
    • Reduced production due to impaired hepatic synthesis of thrombopoietin
  • Chang in INR. maybe low or elevated
    • Most clotting factors are synthesized by the liver.  Reduction in these clotting factors tends to cause reduced enzymatic coagulation.
    • Naturally occurring anticoagulants are also synthesized by the liver.  A deficiency of these tends to augment enzymatic coagulation.
    • Factor VIII is produced by endothelial cells and tends to be upregulated in cirrhosis, augmenting coagulation.

Renal Failure

In severe cases known as Hepatorenal Syndrome.


  • Liver Cancer
  • bone fractures (low vitamin D)
  • Diabetes

Signs and Symptoms of Cirrhosis:

Early stages of how cirrhosis affects the body:

  • Patients may be asymptomatic

Late stages of how cirrhosis affects the body:

  • GI system. 
    • Early indicators usually involve gastrointestinal signs and symptoms such as anorexia, indigestion, nausea, vomiting, constipation, or diarrhea.
  • Respiratory system. 
    • Respiratory symptoms occur due to hepatic insufficiency and portal hypertension.
    • Pleural effusion, and limited thoracic expansion due to abdominal ascites, interfering with efficient gas exchange and leading to hypoxia.
  • Central nervous system. 
    • Lethargy, mental changes, slurred speech, asterixis (flapping tremor), peripheral neuritis, paranoia, hallucinations, extreme obtundation, and ultimately, coma.
  • Hematologic.
    • The patient experiences bleeding tendencies and anemia.
  • Endocrine. 
    • The male patient experiences testicular atrophies
    • the female patient may have menstrual irregularities, gynecomastia, and loss of chest and axillary hair.
  • Skin. 
    • There is severe pruritus, extreme dryness, poor tissue turgor, abnormal pigmentation, spider angiomas, palmar erythema, and possibly jaundice.
  • Hepatic. 
    • Cirrhosis causes jaundice, ascites, hepatomegaly, edema of the legs, hepatic encephalopathy, and hepatic renal syndrome.


  • Liver scan: The liver scan shows abnormal thickening and a liver mass.
  • Liver biopsy; a Liver biopsy is a definitive test for cirrhosis as it detects destruction and fibrosis of the hepatic tissue.
  • Liver imaging: Computed tomography scan, ultrasound, and magnetic resonance imaging may confirm the diagnosis of cirrhosis through visualization of masses, abnormal growths, metastases, and venous malformations.
  • Cholecystography and cholangiography visualize the gallbladder and the biliary duct system.
  • Splenoportal venography: Splenoportal venography visualizes the portal venous system.
  • Percutaneous transhepatic cholangiography: This test differentiates intrahepatic from extrahepatic obstructive jaundice and discloses hepatic pathology and the presence of gallstones.
  • How cirrhosis affects blood count: There is decreased white blood cell count, hemoglobin level, and hematocrit, albumin, or platelets.

Medical Management

Treatment is designed to remove or alleviate the underlying cause of cirrhosis.

  • Diet. The patient may benefit from a high-calorie and medium to high-protein diet.
    •  Once a patient has hepatic encephalopathy, restrict protein intake.
  • Sodium restriction.is usually restricted to 2g/day.
  • Fluid restriction. Fluids are restricted to 1 to 1.5 liters/day.
  • Activity. Rest and moderate exercise is essential.
  • Paracentesis. Paracentesis may help alleviate ascites.
  • Sengstaken-Blakemore or Minnesota tube. The Sengstaken-Blakemore or Minnesota tube may also help control hemorrhage by applying pressure on the bleeding site.

Pharmacologic Therapy

Drug therapy requires special caution because the cirrhotic liver cannot detoxify harmful agents effectively.

  • Octreotide. For esophageal varices.
    • improves renal function, total exchangeable sodium, and peripheral hemodynamics in cirrhotic patients with ascites
    • Helps with esophageal varies by decreasing portal vain hypertension
    • It also controls the emptying of the stomach and bowel
  • Diuretics. Diuretics may be given for edema, however, they require careful monitoring because fluid and electrolyte imbalance may precipitate hepatic encephalopathy.
  • Lactulose. Encephalopathy is treated with lactulose.
  • Antibiotics. Antibiotics are used to decrease intestinal bacteria and reduce ammonia production, one of the causes of encephalopathy.
  • beta blockers. Slow the heart rate, decreases the force of contraction, and also helps with the treatment of esophageal varices
  • Nitrates. Vaso dilator to treat portal hypertension
  • Administer blood products and vitamin K to help with clotting

Surgical Management

Transjugular intrahepatic portosystemic shunt (TIPS) procedure. The TIPS procedure is used for the treatment of varices by upper endoscopy with banding to relieve portal hypertension.

Liver transplant: surgical resect or implantation of a new liver, partial or full

How Cirrhosis Affects the Body and What is the Nursing Management

Nursing management for the patient with cirrhosis of the liver should focus on promoting rest, improving nutritional status, providing skin care, reducing the risk of injury, and monitoring and managing complications.

  • Monitor blood glucose levels (hyperglycemia and hypoglycemia)
  • Assessing sclera and skin color for Jaundice along with urine color: very dark
  • Monitor I’s and O’s very closely, daily weight, monitor ascites and swelling in extremities
  • Activity intolerance, difficulty breathing (no supine), at risk for skin breakdown (turning every 2 hours), elevating feet
  • Administering Lactulose per MD order:  decreases ammonia levels

Nursing Assessment

Assessment of the patient with cirrhosis should include assessing for:

  • Bleeding. Check the patient’s skin, gums, stools, and vomitus for bleeding.
  • Fluid retention. To assess for fluid retention, weigh the patient and measure abdominal girth at least once daily.
  • Mentation. Assess the patient’s level of consciousness often and observe closely for changes in behavior or personality.

Learn more about cirrhosis of the liver by watching this full episode here


00:00 Introduction
01:25 What is Cirrhosis
02:32 What causes Cirrhosis
04:12 What does the liver do
05:39 Functions of the liver
17:32 Complications of Cirrhosis
22:39 What are the signs and symptoms of cirrhosis
29:43 How to diagnose cirrhosis
34:54 Pharmacologic Therapy
37:44 Surgical Management
39:18 Nursing Assessment
42:28 Wrapping up the show


EP 191: Nursing Negligence & HIPPA with Irnise Williams

EP 191: Nursing Negligence & HIPPA with Irnise Williams

Nursing Negligence & HIPPA with Irnise Williams

Nursing negligence is when a nurse fails to do or perform minimum nursing care within the standards of conduct, which results in loss or harm. It can also result from a failure of the nurse to perform their duties or when it is done incorrectly.

While this rarely happens, it is still something that all nurses must be aware of. The lives of our patients are in our hands, it is vital that we are always conscious and mindful of our job and duties as members of the healthcare team. 

Our Guest

In this episode, we would like to introduce you to Irnise Williams. Irnise is an experienced nurse and now an attorney. She has a vast amount of knowledge when it comes to healthcare law.

Irnise has advocated for and trained thousands of healthcare providers to work within their scope of practice. She has also worked with over 100 businesses helping them operate and stay protected by creating systems, solutions, and success through her 5-step framework. 


The questions below are some we’d like to tackle. We often go off-topic, so we don’t expect to hit them all. If you have any ideas, please let us know.

Looking forward to our conversation!

These are the questions you had in Calendly. We’ll go off your questions and wherever else our conversation goes.

  1. Can you give us a background about yourself? 
  2. From a legal standpoint, what can nurses get in trouble for?
  3. What kind of cases do you see most that involve nurses, physicians, or any healthcare professionals?
  4. What is malpractice from a healthcare professional standpoint?
    • What is your experience with malpractice cases?
    • Should every nurse have malpractice insurance?
  5. Other than malpractice insurance, how should nurses protect their licenses?
  6. What Potential Legal Ramifications Do Nurses Face?
  7. What should you do as a healthcare professional to avoid getting sued?
  8. Have HIPPA laws changed at all?
    • How is social media use affected by HIPPA law in the workplace? 
    • Can we talk about nursing stories outside of the hospital setting? 
  9. What is the 66-day business Bootcamp you offer?


Before we end the show, we have one last question we like to ask all our guests. If you had the opportunity to have a Cup of coffee with anybody one last time, who would it be & why? 

Learn more about Nursing Negligence & HIPPA by watching the full episode here! 👇😎


00:00 Introduction
01:50 About Irnise Williams
05:19 The reason why Irnise went to law school
07:30 Transitioning from being a nurse to running a law firm
11:31 What you should do to avoid getting into trouble
14:08 Things that nurses may be held accountable for in court
20:52 The difference between negligence and malpractice
22:46 HIPPA Violations
28:29 Information you shouldn’t post on social media
30:31 Can a healthcare provider sue a hospital
33:52 Does healthcare provider need malpractice insurance
35:06 Other services Irnise can provide
36:47 Legal tips for nursepreneurs
38:31 Responsibilities and liabilities of a travel agency
41:26 Wrapping up the show

EP 190: How to Be a Successful Nursepreneur with Catie Harris

EP 190: How to Be a Successful Nursepreneur with Catie Harris

How to Be a Successful Nursepreneur with Catie Harris

Being a successful nursepreneur doesn’t happen overnight. As nurses, we can handle anything when it comes to our patients. But how about running a business? As I have mentioned, overnight success doesn’t happen right away.

There are steps to that, but what are they? How can you become a successful nurse entrepreneur?

In this episode, we would like to introduce you to Catie Harris, a NursePreneur Mentor who has empowered thousands of nurses in business to monetize their knowledge and skills while inspiring them to change the way healthcare is perceived and delivered.

She strives to undo the perception that nursing care is limited to the hospital setting. Through her intensive nurse business coaching program,

Catie shows nurses around the world how their hard-earned knowledge and skills can transcend the hospital system into a profitable business.


The questions below are some we’d like to tackle. We often go off-topic, so we don’t expect to hit them all. If you have any ideas, please let us know.

Looking forward to our conversation!

These are the questions you had in Calendly. We’ll go off your questions and wherever else our conversation goes.

  1. Can you give us a background about yourself?
  2. What made you leave nursing and become an entrepreneur?
  3. Can you be both a nurse and an entrepreneur? 
    • Nursing gives you income stability which allows you to focus more on your business and not have to necessarily worry about the financials all the time. 
    • Most businesses take 2-3 years to see some income being generated.
  4. How can nurses dig beneath the surface of their careers to find passion, purpose & profit?
    • We often do not understand the power that we have as nurses. The difference we make individually extends far beyond the patient, student, or colleague whose life we change. Each of us has the power to create a ripple effect.
    • What is the origin of nursing purpose to getting into healthcare? Can we channel our purpose into other places?
  5. What are some business ideas that you’ve recently seen nurses participate in?


Before we end the show, we have one last question we like to ask all our guests.

If you had the opportunity to have a Cup of coffee with anybody one last time, who would it be & why? 

To learn more about being a successful nursepreneur, watch our full episode here 👇👇👇


00:00 Introduction
01:56 About Catie Harris
03:49 How has your purpose changed
04:35 Nursing traits that you can use in business
05:35 The pain points of starting a business
07:11 How passion started
09:45 Discovering your passion
12:31 How do you pass success to your clients
14:30 How to deal with not profitable
18:09 Successful nursepreneur businesses
21:18 How to look for the right people to work with
22:36 Hospital Leader vs Entrepreneur Leader
24:30 Overcoming imposter syndrome
25:50 Struggles of running a business
27:41 Big mindset shifts as an entrepreneur
29:34 Failures and motivations
31:49 Balancing work and life
33:42 Tips on starting a business
35:52 How to keep the business organized
39:00 Wrapping up the show

EP 189: Nurse-on-Nurse Violence and Communication

EP 189: Nurse-on-Nurse Violence and Communication

Nurse-on-Nurse Violence and Communication

Nurse-on-nurse violence is a serious issue that’s happening all over the world. An average of two nurses every hour experience being abused in their workplace. And many don’t even file reports about it. 

When we say violence, the first thing that comes to our mind is physical assault but that’s not the only form of violence. In fact, violence also happens in the place of work. OSHA or Occupational Safety Health Administration defines workplace violence as 

“Any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults and even homicide. It can affect and involve employees, clients, customers, and visitors. ” 

In the United States, acts of violence and other injuries are the third-leading causes of fatal occupational injuries. And for nurses, this is sometimes the reality that we face.

How can we avoid this? How can we stop nurse-on-nurse violence? And what can we do in case acts of violence occur in our workplace? 

Our Guest

In this episode, we would like to introduce you to Phil La Duke. Phil is currently employed as a writer, and board member on over ten medical research oversight boards.

We talk about workplace violence and the importance of communication and emotional de-escalation.  


The questions below are some we’d like to tackle. We often go off-topic, so we don’t expect to hit them all. If you have any ideas, please let us know.

Looking forward to our conversation!

These are the questions you had in Calendly. We’ll go off your questions and wherever else our conversation goes.

  1. Share with us your background and experience.
  2. Working with worker safety, what are the most common safety issues or injuries?
    • Where are all the fallouts that cause these to happen?
  3. What made you get into safety?
  4. What are the biggest safety issues in hospitals or in healthcare facilities? 
  5. A survey from Beckers Hospital revealed that 92% of healthcare workers have experienced or witnessed violence from a patient or their caregiver.  
    • How can we combat that?
  6. What does it mean to be part of a medical research board?
  7. What made you start writing books?


Before we end the show, we have one last question we like to ask all our guests.

If you had the opportunity to have a Cup of coffee with anybody one last time, who would it be & why? 

Do you want to know how we can resolve nurse-on-nurse violence? Click here for the full episode 👇👇👇


00:00 Introduction
01:21 About Phil La Duke
05:09 How Phil started working in healthcare
07:44 The Just Culture
09:50 Risk-taking decisions
11:26 How Phil came about to workplace violence
16:47 The weird life of Phil La Duke
21:17 Common workplace violence in a hospital
38:00 Interventions to avoid workplace violence
59:31 How to Deescalate
01:17:54 Wrapping up the show

EP 188: CIWA protocol and Management of Alcohol Withdrawal

EP 188: CIWA protocol and Management of Alcohol Withdrawal

CIWA Protocol and Management of Alcohol Withdrawal

Using CIWA protocol and management of alcohol withdrawal is essential to every alcoholic individual who wants to stay sober. Keep in mind that alcohol dependency does not happen overnight.

It takes years of alcohol consumption to be called an alcoholic.

But why do people drink? What can they gain from it? When a person decides to stay sober, they go through all kinds of changes as their body withdraws from it.

Alcohol withdrawal is not to be taken lightly as someone may exhibit extreme side effects or worse, die from this experience if not supervised. 

If you know is going through alcohol withdrawal, you might have heard about the CIWA Protocol. What is it? And how can it help patients with withdrawal symptoms?

If you are a new nurse or a nursing student who wants to learn all about CIWA protocol, this episode is for you.

Today we will learn about CIWA protocol and how to manage alcohol withdrawal. Keep watching to learn more. 

Alcohol Withdrawl Effects

Symptoms of alcohol withdrawal occur because alcohol is a central nervous system depressant. Alcohol simultaneously enhances inhibitory tone (via modulation of gamma-aminobutyric acid [GABA] activity) and inhibits excitatory tone (via modulation of excitatory amino acid activity). 

In patients with alcohol dependence, only the constant presence of ethanol preserves homeostasis. Abrupt cessation unmasks the adaptive responses to chronic ethanol use, resulting in overactivity of the central nervous system.

Alcohol stimulates GABA receptors. 

What is GABA

GABA is a type of neurotransmitter. Neurotransmitters are chemical messengers in the nervous system.

Messages travel along the nervous system via neurons that pass signals to each other. For example, they might carry a message from the brain to your hand to move away from danger, or they may carry a message from the hand to the brain saying a pot is hot.

As an inhibitory neurotransmitter, GABA blocks certain nerve transmission, known as messages. It prevents the stimulation of neurons.

This means that a neuron that receives a message along the way doesn’t act on it, so the message isn’t sent on to other neurons.

This slowdown in message transition may be helpful because GABA can specifically stop messages related to extreme moods.

In other words, GABA calms your nervous system down, helping you to not become overly anxious or afraid.

  • Gamma-aminobutyric acid — GABA is the major inhibitory neurotransmitter in the brain. Highly specific binding sites for ethanol are found on the GABA receptor complex. Chronic ethanol use induces insensitivity to GABA such that more inhibitor is required to maintain a constant inhibitory tone
  • As alcohol tolerance develops, the individual retains arousal at alcohol concentrations that would normally produce lethargy or even coma in relatively alcohol-naïve individuals. Cessation of alcohol or a reduction from chronically elevated concentrations results in decreased inhibitory tone.

Alcohol Withdraw Signs and Symptoms

Alcohol withdrawal doesn’t happen right away but it does follow a timeline so nurses know what to do during each phase. Here’s what you need to know:


6 hours after you stop drinking

Mild symptoms can start as early as 6 hours after you put down your glass. They can include:

  • Anxiety
  • Shaky hands
  • Headache
  • Nausea
  • Vomiting
  • Insomnia
  • Sweating

12-48 hours after your last drink

More serious problems, including hallucinations, can start in this timeframe and may include hallucinations (about 12-24 hours after you stop drinking) and seizures within the first 2 days after you stop. You can see, feel, or hear things that aren’t there.  

48-72 hours after you stop drinking

Delirium tremens or DTs usually start at this timeframe. These are severe symptoms that include vivid hallucinations and delusions. Only about 5% of people with alcohol withdrawal have them. Those that do may also have:

  • Seizures 
  • Hallucinations
  • Confusion
  • Racing heart
  • High blood pressure 
  • Heart palpitations 
  • Fever
  • Heavy sweating

What is the CIWA protocol? 

The Clinical Institute Withdrawal Assessment Alcohol Scale Revised (CIWA-AR) is an instrument used by medical professionals to assess and diagnose the severity of alcohol withdrawal. The CIWA-AR is one of the most common methods of treating alcohol withdrawal

The CIWA-AR allows physicians to measure the severity of patients’ alcohol withdrawal syndrome, and thus prevent further health complications and treat the withdrawal syndrome accordingly

CIWA Scoring

The CIWA-AR scores on a scale from 0-7 for each symptom and takes less than 2 minutes to complete. By adding up the scores of each 10 symptoms into a total, physicians can determine a severity range for patients’ withdrawal syndrome.

Cumulative scores of less than 8-10 indicate mild withdrawal. Next, scores of 8-15 indicate moderate withdrawal, and scores of 15 or more 15 indicate severe withdrawal with impending possible delirium tremens.

  1. Nausea Vomiting: 0-7
    1. 0 – No nausea, no vomiting 
    2. 1 – mild nausea, no vomiting
    3. 4 – intermittent nausea and dry heaves
    4. 7 – constant nausea, frequent dry heaves, and vomiting
  2. Agitation: 0-7
    1. 0 – normal activity
    2. 1 – somewhat more than normal activity
    3. 4 – moderately fidgety and restless
    4. 7 – paces back and forth or consistently thrashes
  3. Visual disturbances: 0-7
    1. 0 – not present
    2. 1 – very mild sensitivity
    3. 2 – mild sensitivity
    4. 3 – moderate sensitivity
    5. 4 – Moderately severe hallucinations
    6. 5 – severe hallucinations
    7. 6 – extremely severe hallucinations
    8. 7 – continuous hallucinations
  4. Tremor: 0-7
    1. 0 – no tremor
    2. 1 – not visible but can be felt
    3. 4 – moderate with the patient’s arms extended
    4. 7 – severe, even with arms not extended
  5. Tactile Disturbance: 0-7
    1. 0 – none
    2. 1 – very mild itching, pins, and needles, burning, or numbness
    3. 2 – mind itching, pins, and needles, burning, or numbness
    4. 3 – moderate itching, pins, and needles, burning, or numbness
    5. 4 – moderately severe hallucinations
    6. 5 – severe hallucinations
    7. 6 – extremely severe hallucinations
    8. 7 – continuous hallucinations
  6. Headache fullness in head: 0-7
    1. 0 – not present
    2. 1 – very mild
    3. 2 – mild
    4. 3 – moderate
    5. 4 – moderately severe
    6. 5 – severe
    7. 6 – very severe
    8. 7 – extremely severe
  7. Paroxysmal sweats 0-7
    1. 0 – no sweat
    2. 1 – barely perceptible sweating, palms moist
    3. 4 – beads of sweat obvious on the forehead
    4. 7 – drenching sweats
  8. Auditory disturbances: 0-7
    1. 0 – not present
    2. 1 – very mild harshness or ability to frighten
    3. 2 – mild harshness or ability to frighten
    4. 3 – moderate harshness or ability to frighten
    5. 4 – moderately severe hallucinations
    6. 5 – severe hallucinations
    7. 6 – extremely severe hallucinations
    8. 7 – continuous hallucinations
  9. Orientation and clouding of sensorium: 0-4
    1. 0 – oriented and can do serial additions
    2. 1 – cannot do serial additions and is uncertain about dates
    3. 2 – disoriented for date by no more than 2 calendar days
    4. 3 – disoriented for date by more than 2 calendar days
    5. 4 – disoriented for place and/or person
  10. Anxiety: 0-7
    1.  0 – no anxiety at ease
    2. 1 – mildly anxious
    3. 4 – moderately anxious or guarded, so anxiety is inferred
    4. 7 – equivalent to acute panic states as seen in severe delirium or acute delirium or acute schizophrenic reaction.

The total score is a simple sum of each item score (maximum score is 67)

Score results:

  • <10: Very mild withdrawal
  • 10 to 15: Mild withdrawal
  • 16 to 20: Modest withdrawal
  • >20: Severe withdrawal

Drug Dosage

  • 5-9: Lorazepam 1mg IV q 4h
  • 10-14: Lorazepam 2mg IV q 2h
  • 15-19: lorazepam 3mg IV q 1h
  • 20-24: Lorazepam 4mg IV q30min
  • 25-29: Lorazepam 5mg IV q15min
  • 30-34: Lorazepam 6mg IV q10min

Seizure precautions

  • Reduce Environmental Stimuli
  • Pad Side Rails
  • Bed Lowest Position
  • Oxygen and Suction Available

Drug selection

Benzodiazepines are used to treat the psychomotor agitation most patients experience during withdrawal and to prevent progression from minor withdrawal symptoms to major ones. 

Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium) are used most frequently to treat or prevent alcohol withdrawal, but other benzodiazepines may be used. In general, long-acting benzodiazepines with active metabolites (eg, diazepam or chlordiazepoxide) are preferred because they seem to result in a smoother clinical course with a lower chance of recurrent withdrawal or seizures.


Benzodiazepines are a type of sedative medication. This means they slow down the body and brain’s functions. These drugs increase the effects of GABA on your brain and body. It means these drugs can:

    • make you feel relaxed and sleepy (sedation)
    • reduce your anxiety
    • relax your muscles.

Dexmedetomidine (Precedex) as an adjunct treatment for severe alcohol withdrawal in the ICU:

  • Precedex belongs to a class of drugs called Sedatives.
  • Precedex may cause serious side effects including:
    • low or high blood pressure
    • slow heart rate
    • abnormal heart rate

To learn more about the CIWA protocol and how to manage withdrawal symptoms, click here 👇👇👇


00:00 Introduction
01:29 What happens to someone that goes through alcohol withdrawal?
02:53 How GABA affects the body
05:06 Alcohol affects depression and anxiety
05:50 How to deal with alcoholic patients
08:08 Families should create a safe space
09:10 Signs and symptoms of alcohol withdrawal
13:07 What is CIWA Protocol?
15:20 Intravenous (IV) over Per Oral (PO)
17:34 The CIWA Protocol Scale
21:32 Drug Dosages
23:45 Seizure precautions
24:23 Drug Selection
28:22 Physical restraints
29:54 Wrapping up the episode