EP 199: The Renal System and RAAS

EP 199: The Renal System and RAAS

The Renal System

The renal system produces, stores, and eliminates urine. Kidneys make urine by filtering wastes and extra water from the blood. Urine travels from the kidneys through two thin tubes called ureters and fills the bladder. When the bladder is full of urine, a person urinates through the urethra to eliminate the waste.

Functions of the Kidneys

The kidneys are located on either side of the spine at the lowest level of the rib cage, consisting of the functional unit called a nephron. 

There are about one million nephrons in each kidney; these nephrons consist of tiny blood vessels called glomerulus attached to a tubule. 

When blood enters the glomerulus, it is filtered, and the remaining fluid passes to the tubule. In the tubule, minerals, elements, chemicals, and water are absorbed or filtered according to the body’s needs to create the final product, urine.

Our kidneys maintain a delicate balance of water and electrolytes in the body and remove excessive waste:

  • Remove wastes, urea, and ammonia, from the blood.
  • Maintain fluid status balance in the body by holding or retaining water and releasing and removing water from the bloodstream
  • It maintains the electrolyte balance of the blood.
  • Maintain acid-base/pH balance of the blood
  • Assist with endocrine functions such as the production of erythropoietin and calcitriol.
    • It is needed to produce red blood cells and calcium reabsorption, respectively.
  • Produce the enzyme renin
    • Help regulate blood pressure.
  • Convert vitamin D into its active form

Fun Fact: 

  • Every 24 hours, your kidney filters 200 quarts of fluid. About two quarts are removed from the body, and 198 quarts are returned to the bloodstream. 
  • The right kidney sits lower than the left kidney. 
    • It helps accommodate the large size of the liver, right above the right kidney.
  • We call it REabsorption rather the just absorption because the substances filtered from the glomerulus were already absorbed through the GI tract and taken into the bloodstream. Then the substances travel through the body via the heart and are sent to the kidneys through the renal artery to be filtered out. Therefore, our body reabsorbs these nutrients based on their needs, and the leftovers are excreted in the urine.

Anatomy of the Kidney

As a nurse and a nursing student, you’ll need to know these most critical parts of the kidney to understand how the renal system works.

Renal Capsule 

  • The outer layer of the kidney protects the kidney from outside organ infections. 

Renal cortex: 

  • A layer outside contains the renal corpuscles, which house the glomerulus and Bowman’s capsule, whose primary functions are to FILTER the urine and renal tubules. 

Renal medulla: 

  • The inside layer is located within the renal pyramids. It is hypertonic and very salty. Along with the nephron, these conditions help maintain water and salt balance in our body, specifically the Loop of Henle.

Renal artery:  

  • The renal artery takes oxygenated blood from the heart and moves it to the kidney to be filtered. It branches off around the renal columns into the renal cortex, into arterioles, and finally to the peritubular capillaries.

Renal vein:

  • The renal veins take filtered blood to heart for re-oxygenation and are pumped throughout the body. It comes from the efferent arterioles.

Renal pyramids: 

  • Lie Within the renal medulla contains the loop of Henle and parts of the collecting tubule.

Renal papilla, minor and significant calyx:

  • Pointed projections of the renal pyramid play a role in draining urine along with the renal pelvis, ureters, bladder, and urethra.


  • The functional part of the kidneys. 
  • Filters the blood via the renal corpuscle
  • Reabsorbs minerals/water and secretes waste via the renal tubule
  • Produces urine which drains down into the ureters, is stored in the bladder, and voided out via the urethra.
  • Each nephron is composed of 
    • Renal corpuscle (glomerulus within Bowman’s capsule)
    • Proximal tubule
    • An intermediate tubule (loop of Henle)
    • A distal convoluted tubule, a connecting tubule, and cortical, outer medullary, and inner medullary collecting ducts.


  • Lies within the nephron
  • Circular capillaries that have incredibly high pressure helps perform ULTRAFILTRATION.

Bowman’s capsule

  • Forms a cup-like sack around the glomerulus
  • It helps the glomerulus filter blood 

The Nephron and blood supply

Blood enters the afferent arteriole and sends blood to the first part of the nephron, called the glomerulus.

In the glomerulus, blood will be filtered, and filtrate will be created, a liquid consisting of the collection of fluid and particles from the blood. The filtrate will “drip” down into a capsule surrounding the glomerulus called Bowman’s capsule.

  • Bowman’s capsule collects the filtrate.
    • Water, NA, CL, CA, K, Mg, Phos, Bicarb, amino acids, glucose, creatinine, and urea.

Then the filtered blood exits via the efferent arterioles to the peritubular capillaries surrounding the nephrons. 

Peritubular capillaries carry the reabsorbed nutrients from the filtrate back into the body’s system to the renal vein. They secrete urea, ions, and drugs in the blood into the tubules.

The created filtrate then flows through the proximal convoluted tubule (PCT); here, the tubule reabsorbs most of the parts of the filtrate that we need to function that just came from the Bowman’s capsule.

Then the filtrate enters the Loop of Henle; we are now in the renal medulla. The loop of Henle has a descending limb and ascending limb. Its goal is to concentrate the urine via the renal medulla. The renal medulla’s interstitial fluid is hypertonic, helping reabsorb water from the filtrate to maintain the body’s water and salt balance.

  • Descending limb is only permeable to water.
  • Ascending limb is only permeable to ions.

The filtrate then enters the distal convoluted tubule, where more substances are reabsorbed and secreted. 

Then it travels to the collecting tubule, where parts of the filtrate are reabsorbed. Finally, the filtrate leaves the collecting tubule as urine which flow through the renal papilla, minor/major calyx, renal pelvis, ureters, bladder, and urethra.

Kidney and Blood Pressure Management 

The renin-angiotensin-aldosterone system (RAAS) is the system of hormones, proteins, enzymes, and reactions that regulate your blood pressure and blood volume long-term.

It regulates your blood pressure by increasing sodium (salt) reabsorption, water reabsorption (retention), and vascular tone (the degree to which your blood vessels constrict or narrow). The RAAS consists of three major substances including:

  • Renin (an enzyme).
  • Angiotensin II (a hormone).
  • Aldosterone (a hormone).

RAAS System

  • Increases blood pressure when it drops too low by activating Angiotensin II
    • Angiotensin II increases vasoconstriction, causing an increase in blood pressure. Conserves sodium and water to increase volume. Aldosterone and ADH are released. 
  • RAAS steps
  1. Blood pressure drops too low. 
  2. The sympathetic nervous system sends nerve impulses to Juxtaglomerular Cells in the kidneys to release RENIN.
  3. RENIN present in the blood will activate ANGIOTENSINOGEN in the liver.
  4. ANGIOTENSINOGEN then turns into ANGIOTENSIN I causing a release of ACE
  5. ACE is Angiotensin-Converting Enzyme. ACE converts Angiotensin I into ANGIOTENSIN II
  6. ANGIOTENSIN II activation will cause
  7. Vasoconstriction
    • Increases systemic vascular resistance (SVR) and blood pressure.
  1. Increase Blood Volume
      • Kidneys will keep water and sodium.
      • The adrenal cortex gland will be triggered by angiotensin II to release aldosterone. Aldosterone will also cause the kidneys to keep sodium and water and excrete potassium.
    • Angiotensin II triggers the pituitary gland to release ADH. It causes the kidneys to keep water.

2. Increased blood pressure

To learn more about the renal system, click here for the full episode 👇👇👇


00:00 Introduction
02:10 The functional parts of the kidney
03:18 What does a kidney do
04:40 Kidney fun facts
05:40 Anatomy of the kidney
10:00 The nephron and blood supply
15:48 Kidney and blood pressure management
17:39 How the Renin-Angiotensin-Aldosterone System (RAAS) works
21:50 Further views on the episode
24:02 Wrapping up the show



Miscommunication Among Nurses and How to Avoid It

Miscommunication Among Nurses and How to Avoid It

Miscommunication Among Nurses and How to Avoid It

Nurses are among the essential workers in the healthcare world, especially now that we have a pandemic. However, miscommunication among nurses is an issue that happens quite often. How can this be avoided? What causes miscommunication among nurses? 

How Can Miscommunication Among Nurses Be Avoided?

There are a couple of ways that nurses can avoid miscommunication. Keep in mind that being able to relay the correct information about their patients can make a difference in nursing care. As a nurse, you must provide accurate data regarding their condition so proper nursing can be given. Here’s how you can do that:

1. Make eye contact when endorsing patients.

There is a sense of relief whenever the shift is over, especially if it has been a toxic one since you first clocked in. While it is exciting to exit the nurse’s station once your shift is over, make proper endorsements first. The best way to ensure no miscommunication is to make eye contact with the next nurse on duty when endorsing the patient’s chart. 

Take the time to explain everything, from the procedures done to the patient, medications given, the diagnosis (if you have to), and even the physician/s who came to check in with them.

Making eye contact gives you the chance to scan for any uncertainty in their face or if they understood what was said to them. It is also the best way to engage someone in a conversation and ensure they listen to what you say. 

2. Use bedside nursing boards.

Bedside nursing boards are also commonly known as bed-census boards. These can help you with an open line of communication among nurses in the team/building, the patient’s families, and you as health care providers.

The boards help with the patient’s condition and communicate with their families and the rest of the hospital staff. Understand that there are tons of healthcare providers in the hospital working on patients. Failing to communicate properly can lead to negative consequences.

Bedside boards are essential in providing reports to the next nurse on duty. It can help them understand what happened during your shift and fill them in on the patient’s history if this is their first time handling them. Bed-census boards also prove to the patient’s families that proper care is given to their loved ones. 

3. Take time to talk to your patients.

Nurses are often busy in each shift, and it is not surprising that they cannot give their patients full attention. However, taking the time to check on your patients, listen to their concerns, and show that you can help are enough to put them at ease. It is also a good nursing quality to have. 

Allowing a few minutes of one-on-one conversation with your patients can be rewarding. It is easier to see how they are improving and establish a sense of trust as their nurse. Although you may not do this every day, it is best to create a routine and stick to it. 

How Can Nurses Improve Their Communication Skills

Improving communication among nurses is possible. To do this, nurses like you practice patience and become better listeners. When you listen, you don’t offer one ear but both. Keep in mind that you are working with other nurses who are also busy. Listening to each other is crucial to providing better services to patients. 
You can also avoid communication conflict when you practice active listening. Active listening is repeating the key points of the conversation to the speaker. So, make it a habit to listen to your coworkers and improve your listening skills. 
Another way to avoid miscommunication among nurses is not to interrupt the speaker. This could be helpful during endorsements at the end of the shift. Allow the person to finish talking first before asking questions.
Keep in mind that even the slightest cues can determine the condition of patients. Resist the urge to ask questions whenever someone is talking. 
As a nurse, you must also learn to maintain a positive attitude. Remember, happiness is contagious! Your positive outlook can also affect your coworkers and even your patients.
When things get a little serious, be sure to keep your emotions in check. Your nurse training taught you to remain professional and courteous during conversations. No matter how angry or upset you are, keep it cool.
Be aware that your emotions can affect others and your ability to communicate at work. When you do so, miscommunication among nurses will not happen.

In Closing

Communication is an essential part of patient care, and when this is done accordingly, it is nurses can work together effectively. If you feel like you or your coworkers are missing out on proper communication, take the step to address this issue. It will surely help your team and other hospital staff to do better as you provide nursing care to your patients. 


EP 194: Noninvasive Positive Pressure Ventilation with Aurika Savickaite

EP 194: Noninvasive Positive Pressure Ventilation with Aurika Savickaite

Noninvasive Positive Pressure Ventilation with Aurika Savickaite

Noninvasive positive pressure ventilation is a recognized alternative in managing selected cases of acute respiratory failure. It is a form of mechanical support where positive pressure delivers a mixture of oxygen and air through the respiratory tree using a noninvasive interface. It could be through standard ICU ventilators or portable devices. Now, if this is something new to you and you want to learn about NPPV, this episode is for you. 

For this episode, we would like to introduce you to Aurika Savickaite. Aurika has worked as a registered nurse and patient care manager at the University of Chicago Medical Center’s Medical Intensive Care Unit. Aurika was involved in successfully testing the helmet ventilator in the ICU at the University of Chicago during a three-year trial study.

In the episode, we focus on the benefits of helmet-based noninvasive positive pressure ventilation on patient outcomes. 


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 little background about yourself?
  2. What is Noninvasive Positive Pressure Ventilation (NIPPV), and what are some typical examples of this you see at the hospital?
  3. What made you decide to be involved in creating helmet-based ventilation?
    • What exactly is it? 
    • Can you explain the product and how it works?
  4. How does helmet-based ventilation compare to our current noninvasive positive pressure ventilation? 
    •  What is the cost difference?
    • Can it lead to fewer intubations? 
  5. How have the helmets been working out in New Zealand? 
  6. You’re a problem solver at heart. Are there any other things you are working to improve? Inside or outside of the healthcare setting? 


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? 



YouTube channel:

Infographics: https://www.helmetbasedventilation.com/post/infographic-comparison-bubble-helmet-hood-niv-face-mask-invasive-mechanical-ventilation 

Online training course:

Links to two articles mentioned in the podcast:

Learn more about Noninvasive Positive Pressure Ventilation in this full episode 👇👇👇


00:00 Introduction
02:15 About Aurika Savickaite
04:35 How does a ventilation helmet look like
08:28 The cons of using the facemask
12:07 Why does a patient needs positive pressure ventilation
17:55 The advantage of using the helmet interface over the facemask
25:39 Helmet interface has lesser chances of intubation
30:14 Is there a noise issue with the helmet?
33:50 How has the helmet helped the world
38:38 Embracing Innovations to improving patient care
43:31 To much technology is not always better
48:16 Improving patient care should start with nurses
55:25 Other things that interest Aurika
01:01:12 Wrapping up the show

Things to Know About Being a Crisis Travel Nurse

Things to Know About Being a Crisis Travel Nurse

Things to Know About Being a Crisis Travel Nurse

Being a crisis travel nurse has its perks, but it comes with real responsibilities too. One of these responsibilities is when you respond to a crisis. As a crisis travel nurse, you must assist wherever this crisis calls you. If you are interested in working as a travel nurse, it is best to understand what you are getting into and how it can help you as a travel nurse. 

Things to Know About Being a Crisis Travel Nurse

As a travel nurse, you have the opportunity to go to different parts of the country and offer assistance. That said, it is also one of your jobs to answer in times of crisis. A crisis contract is crucial to get things started. But, what do you need to be qualified as a crisis travel nurse? Here’s what you need to know. 

There are no additional requirements for travel nurses with crisis contracts. However, you are most likely able to qualify further if you have the following RN certifications:

  • Certification in Critical Care Nurse
  • Certified Emergency Nurse
  • Certification in Pediatric Nurse

To become certified in these departments, you must have an Associate’s Degree, BSN or MSN. Higher degrees are even better. You must also have experience working in Cardia Care units, Surgical ICUs, ICUs, trauma units, transport, and flight operations, specializing in emergency or life-threatening conditions [1]


Every job has a contract to follow, and a crisis contract is not different. However, there are a few differences that you should know. They are as follows:

The crisis assignment of travel nurses often comes without warning. An event can happen anytime, like a natural disaster. The pandemic is one example of a crisis that went without any notice. Often, a crisis assignment is face-paced and involves high-stress levels. The duration of your job will also depend on how long the crisis is at hand. While the pay is higher for crisis travel nurses, it can be demanding.

Benefits of Being a Crisis Travel Nurse

The crisis assignment of travel nurses often comes without warning. An event can happen anytime, like a natural disaster. The pandemic is one example of a crisis that went without any notice.

Often, a crisis assignment is face-paced and involves high-stress levels. The duration of your job will also depend on how long the crisis is at hand. While the pay is higher for crisis travel nurses, it can be demanding. 

As a crisis travel nurse, there are benefits when you accept the job. One of them is the benefit of a high paid salary. Because of the demands, you can receive 10-100% more than regular nursing staff jobs [2]

You also get to obtain housing, food, and incidental allowances, as well as bonuses for extra shifts. There are also additional shift incentives, primarily if you work night duty or when the health care facility is short-staffed.  

While this sounds good, there are also some downsides to being a crisis travel nurse. For one, you don’t know how long your contract will last, or it will be dropped at the last minute. It can also be an inconvenience because a crisis is not planned. The work is also demanding and often involves critical situations. So, you don’t know what you are in for. 

Before Agreeing to Be a Crisis Travel Nurse

Before agreeing on the job and taking on the risks, remember these three things before signing your contract. 

  • Always consider the location – before you agree on the job, always consider the place of your assignment first. Take the pandemic, for example; some states have higher Covid-19 cases than others. It is also essential to do your research before signing up for the job. 
  • Follow safety protocols – taking a crisis travel nurse job always involves risks. It is also why the pay is higher compared to other nursing jobs. If you are deployed for a job during this pandemic, wearing the proper PPE while at work, wearing face masks, and social distancing are vital. Of course, each crisis differs, so it is best to observe safety protocols. 
  • Consider the pay – crisis travel nurses are paid higher than usual because of the risks involved. However, be on the lookout for agencies that offer ridiculous salary amounts. Often, these contracts are cut off short because of budget reasons. It is also why you should consider contracts with reasonable pay to avoid losing them. 

Being a Crisis Travel Nurse Today is Vital

If you are already a travel nurse, you don’t need many requirements to work in this field. However, working with a good travel nursing agency is a must to set you up with the right job. Your recruiter can help guide you and provide insight on your next crisis travel nursing assignment. Make sure to work only with the best.


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.1 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