Unique Plan Description: Phenobarbital for Severe or Benzo Resistant AWS
Plan Selection Display: Phenobarbital for Severe or Benzo Resistant AWS
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2024-04-02 16:39:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-04-19 12:03:01
Available at all facilities: Yes

Phenobarbital for Severe or Benzo Resistant AWS
Admit/Discharge/Transfer
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Vital Signs
	Vital Signs
		T;N, (IV/IM doses) every 30 minutes x 2 after each IV/IM Phenobarbital administration then VS per unit specific requirements
			Comment: Hold phenobarbital for RR< 10, or RASS <-2; Notify provider for SBP<90, HR <60
		T;N, (PO/Maintenance doses) every 4 hours
			Comment: Hold phenobarbital for RR< 10, or RASS <-2; Notify provider for SBP<90, HR <60
Medications
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	PHENobarbital
		97.2 mg, Tab, By Mouth, Q8H-Sch, STAT, T;N, duration: 24 hr
			Comment: (part 1of 4) Hold for RR< 10, or RASS <-2
		64.8 mg, Tab, By Mouth, Q8H-Sch, T+1;N, duration: 24 hr
			Comment: (part 2 of 4) Hold for RR< 10, or RASS <-2
		64.8 mg, Tab, By Mouth, Q12H-Sch, T+2;N, duration: 24 hr
			Comment: (part 3 of 4) Hold for RR< 10, or RASS <-2
		32.4 mg, Tab, By Mouth, Q12H-Sch, T+3;N, duration: 24 hr
			Comment: (part 4 of 4) Hold for RR< 10, or RASS <-2
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	PHENobarbital IVPB
		4 mg/kg, INT, IVPB, Once
			Comment: Loading dose 1 of 3) Hold for RR< 10, or RASS <-2 If loading dose completed and RASS remains > +2, may administer next Loading dose in 30 minutes
		3 mg/kg, INT, IVPB, Q3H, T;N+180, duration: 2 Dose(s)/Time(s)
			Comment: Loading dose 2 & 3 of 3) Hold for RR< 10, or RASS <-2 If loading dose completed and RASS remains > +2, may administer next Loading dose in 30 minutes
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	PHENobarbital
		64.8 mg, Tab, By Mouth, Q12H-Sch, T;N+1080, duration: 2 Dose(s)/Time(s)
			Comment: (Taper dose 1 of 3) Hold for RR< 10, or RASS <-2
		32.4 mg, Tab, By Mouth, Q12H-Sch, T;N+2520, duration: 2 Dose(s)/Time(s)
			Comment: Taper dose 2 of 3) Hold for RR< 10, or RASS <-2
		32.4 mg, Tab, By Mouth, Q24H-Sch, T;N+3960, duration: 1 Dose(s)/Time(s)
			Comment: (Taper dose 3 of 3) Hold for RR< 10, or RASS <-2
Breakthrough
	QUEtiapine
		12.5 mg, Tab, By Mouth, Q6H, PRN agitation
		25 mg, Tab, By Mouth, Q6H, PRN agitation
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	haloperidol  Injectable
		2 mg, Injection, IV Push, Q4H, PRN agitation
			Comment: If unable to administer antipsychotic by mouth
		5 mg, Injection, IV Push, Q4H, PRN agitation
			Comment: If unable to administer antipsychotic by mouth
Other
	famotidine
		20 mg, Tab, By Mouth, BID, PRN indigestion
	cloNIDine
		0.1 mg, Tab, By Mouth, Q1H, PRN see comment
			Comment: For SBP>150 mmHg to a maximum of 0.6 mg/24 hours. Contact MD if ineffective
	folic acid
		1 mg, Tab, By Mouth, DAILY, duration: 30 Day(s)
	thiamine
		100 mg, Tab, By Mouth, DAILY, duration: 5 Day(s)
		100 mg, Injection, IV Push, DAILY, duration: 5 Day(s)
	multivitamin Oral Tablet
		1 TAB, Tab, By Mouth, DAILY
			Comment: (give with food)
	ondansetron
		4 mg, Tablet-Disintegrating, By Mouth, Q6H, PRN nausea and/or vomiting
		4 mg, Injection, IV Push, Q6H, PRN nausea and/or vomiting
			Comment: use if patient unable to take PO
	traZODone
		100 mg, Tab, By Mouth, QHS, PRN insomnia
			Comment: Do Not Give after 3:00am or during patient's normal wake hours
	nicotine
		2 mg, Gum, By Mouth, Q1H, PRN smoking cessation
		4 mg, Gum, By Mouth, Q1H, PRN smoking cessation
Patient Care

	Cardiac Telemetry Monitoring
		Telemetry Indications: Other
	Notify MD
		SBP < 90, HR<50; Respiratory Rate <10, RASS </= -2, concern for airway compromise or if symptoms of withdrawal not controlled by phenobarbital dosing.
		If RASS >/=  +2 after receiving loading dose
		with any Phenobarbital doses held
Therapies
	Consult Physical Therapy, Evaluate and Treat
		
	End Tidal CO2 (ETCO2) Monitoring
		T;N
			Comment: Continuous
Consults/Follow-up
	Consult Social Work
		T;N
	Consult Behavioral Health
		Reason for Referral: Alcohol Withdrawal
	Pharmacy Consult
		Patient receiving phenobarbital; Medication review and drug interactions due to the risk of additive side effects, concomitant benzodiazepines are NOT recommended for the management of AWS. Discontinue any standing and PRN benzodiazepine orders.
			Comment: Pharmacy to adjust for renal dosing for creatinine clearance </= 10, and dosing considerations for antipsychotic in patients =65 years

Oxygen Protocol
Therapies
Respiratory Therapy
	Oxygen Therapy
		T;N
	Pulse Oximetry Spot Check RT
		T;N, BID
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID

nicotine 14 mg/24 hr Patch
Medications

	nicotine
		14 mg, Patch, TOPICAL, DAILY
	nicotine Patch Removal
		Patch Removal, Patch, TOPICAL, DAILY, T+1;0900
Patient Care
	Medication patch site check
		T;N+720, Q12H-Sch

nicotine 21 mg/24 hr Patch
Medications
	nicotine
		21 mg, Patch, TOPICAL, DAILY
	nicotine Patch Removal
		Patch Removal, Patch, TOPICAL, DAILY, T+1;0900
Patient Care
	Medication patch site check
		T;N+720, Q12H-Sch

nicotine 7 mg/24 hr Patch
Medications
	nicotine
		7 mg, Patch, TOPICAL, DAILY
	nicotine Patch Removal
		Patch Removal, Patch, TOPICAL, DAILY, T;N+1440
Patient Care
	Medication patch site check
		T;N+720, Q12H-Sch

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NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase