Intraoperative Alcohol Withdrawal Syndrome: A Coincidence or Precipitation?

As the prevalence of alcohol dependence is approximately half in surgical patients with an alcohol use disorder, anesthetist often encounters such patients in the perioperative settings. Alcohol withdrawal syndrome (AWS) is one of the most feared complications of alcohol dependence and can be fatal if not managed actively. A 61-year-old man, alcoholic with 50？h of abstinence before surgery, received spinal anesthesia for surgery for femoral neck fracture. To facilitate positioning for spinal anesthesia, fascia iliaca compartmental block with 0.25% bupivacaine (30？mL) was administered 30？min prior to spinal block. Later, in the intraoperative period the patient developed AWS; however, the features were similar to that of local anesthetic toxicity. The case was successfully managed with intravenous midazolam, esmolol, and propofol infusion. Due to similarity of clinical features of AWS and mild local anesthetic toxicity, an anesthetist should be in a position to differentiate the condition promptly and manage it aggressively. 1. Introduction Alcohol dependence (AD) is high in patients with an alcohol use disorder (AUD) presenting for surgery [1]. Therefore, encountering such patients in anesthetic practice is not unlikely. However, 1%–24% of surgical patients with a history of AUD are missed during routine clinical assessment [2, 3]. Dependent patients show higher morbidity and have more adverse events such as infection or cardiopulmonary complication. Alcohol withdrawal syndrome (AWS) is one of the most feared complications of AD, and if untreated the mortality is as high as 15% [4]. Although AWS in perioperative setting is observed more commonly in the postoperative period, we report a case of AWS that developed in the intraoperative period and review the possible factors for its precipitation. 2. Case Description A 61-year-old man weighing 50？kg was scheduled for open reduction and internal fixation of traumatic intertrochanteric fracture left femur under regional anesthesia. He had a history of chronic alcoholism with 50？h of abstinence before surgery. Physical examination was unremarkable. Laboratory findings revealed mild elevation of liver enzymes. With overnight fasting, the patient received aspiration prophylaxis, prophylactic intravenous multivitamins, and oral lorazepam 2？mg at bedtime and 2？h before surgery. On arrival to the block room, intravenous line was secured and standard monitoring was applied. Left fascia iliaca compartmental block (FICB) with bupivacaine 0.25% (30？mL) was administered via landmark technique to facilitate positioning