Impact of a Pharmacist-Driven Phenobarbital Protocol on ICU Length of Stay in Alcohol Withdrawal

Introduction: Alcohol withdrawal syndrome (AWS) is a life-threatening condition with increased risk of seizure and death. Phenobarbital (PHB), a barbiturate used for seizure and AWS treatment, has made a resurgence due to its’ efficacy in benzodiazepine refractory withdrawal. Due to risks associated with excessive PHB dosing such as respiratory depression, a pharmacist-directed PHB protocol was implemented. This study aims to evaluate the impact of a pharmacist-directed PHB protocol on intensive care unit (ICU) length of stay in patients with AWS.


Methods: We performed a pre-post cohort study that included adult patients who received PHB for treatment of AWS in the ICU at three hospitals within a health system. Patients were excluded if they transitioned to comfort care measures within 24 hours of PHB initiation, received PHB after admission day 5, or received PHB for alternative indications. The primary outcome was ICU length of stay. Secondary outcomes included adjunct sedation utilization, time to AWS resolution, duration of mechanical ventilation, and hospital length of stay.


Results: A total of 102 patients were included from March 2020 to August 2024; 33 pre-protocol implementation in February 2022 and 69 post-protocol implementation. Patients in the post-protocol cohort were significantly older (54.5 vs 49.2 years, p = 0.04) and more frequently admitted to the neurotrauma ICU (29.0% vs 3.0%) than the cardiovascular ICU (8.7% vs 33.3%) when compared to the pre-protocol cohort. The primary outcome of mean ICU length of stay was significantly lower in the post-protocol cohort (64.1 hours vs 89.6 hours, p = 0.002). We observed a reduction in need for adjunct dexmedetomidine utilization (50.7% vs 78.8%, p = 0.01), decreased duration of mechanical ventilation (39.6 vs 83.4 hours, p = 0.02), and decreased hospital length of stay (140.4 hours vs 218.8 hours, p < 0.001).


Conclusions: A pharmacist-driven PHB protocol is an effective and advantageous strategy in the management of AWS in the care of ICU patients. Following protocol implementation, patients had a reduction in ICU and overall hospital length of stay.