This study looking at pre and post-phenobarbital order set use to treat inpatient alcohol withdrawal syndrome found:
“AWS symptoms resolved more rapidly after implementation, with a 4.2- to 5.0-point reduction in daily maximum CIWA-Ar scores at 24 to 96 hours from hospital presentation, 30.1-hour reduction in AWS treatment duration (95% CI, 16.7-43.5 hours), and 2.2-day reduction in time to hospital discharge (95% CI, 0.7-3.7 days). Safety outcomes did not significantly differ before and after implementation.”
Remember phenobarbital can be used for alcohol withdrawal for our ED patients as well.
Here is the protocol:
Nursing
Vital signs 10 minutes after phenobarbital loading dose
Clinical Institute Withdrawal Assessment for Alcohol Revised (CIWA-Ar) every 1-4 hours based on score
Loading Dose
Phenobarbital 15 mg/kg intravenous piggyback (recommended for most patients)
Phenobarbital 10 mg/kg intravenous piggyback (low risk or heavily pretreated with benzodiazepines)
As-Needed Doses
Phenobarbital 130 mg intravenous twice as needed for uncontrolled agitation or CIWA-Ar ?15
Phenobarbital 260 mg intravenous once as needed for uncontrolled agitation or CIWA-Ar ?15
References
Wolpaw BJ, Oren H, Quinnan-Hostein L, et al. Hospital-Wide Implementation, Clinical Outcomes, and Safety of Phenobarbital for Alcohol Withdrawal. JAMA Netw Open. 2025;8(8):e2528694. doi:10.1001/jamanetworkopen.2025.28694
