Alcohol use disorder and withdrawal after ankle fixation48-year-old man, 78 kg, for urgent fixation of an unstable ankle fracture after a fall last night

The patient

The examiner asks

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1. Consider

   What are your concerns?

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   • A 48-year-old with heavy daily drinking, cardiomyopathy and neuropathy, for urgent ankle fixation. Patient
   • Intoxicated, dependent, or both? His last drink was 10 hours ago, so withdrawal may be starting. Disease
   • Alcohol harms his liver, heart, nerves and brain; I examine for each.
   • His cardiomyopathy makes him very sensitive to myocardial depressant drugs.
   • He is malnourished: thiamine deficiency risks Wernicke–Korsakoff, especially when he gets glucose.
   • More acid and slow gastric emptying raise his aspiration risk. Airway

2. Prepare

   Take me through his cardiac risk assessment.

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   • I'd use the ACC/AHA stepwise pathway, applied to him. Disease
   • Urgency: urgent; his unstable fracture threatens the limb, but there is time to assess. Stem trigger
   • Active cardiac conditions: none if his failure is compensated, with no arrhythmia or severe valve lesion. Disease
   • Risk score: heart failure is his only RCRI item, so RCRI 1; ankle surgery isn't high-risk.
   • Functional capacity: unknown; his fracture stops him walking, so METs can't guide me.
   • Decision: RCRI 1 is low risk, so I proceed once his fluids and electrolytes are optimised.

3. Prepare

   How will you prepare him?

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   • Thiamine IV before any glucose, with folate and vitamin B12. (Disease)
   • Magnesium 1–2 g IV over 15 minutes; potassium 20–40 mEq over 30 minutes by central line with ECG.
   • Withdrawal scored on the CIWA-Ar: tremor, sweating, anxiety, agitation, hallucinations.
   • A benzodiazepine regimen titrated to his score, mainly to prevent withdrawal seizures.
   • Liver tests, clotting and platelets before any block.
   • Regular glucose checks; his glycogen stores are poor.

4. Plan

   How will you anaesthetise him?

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   • Chronic drinking raises his anaesthetic needs; any intoxication lowers them, so I titrate. Disease
   • Slow, titrated induction for his weak ventricle; rapid sequence for aspiration risk. Airway
   • His neuropathy is a relative contraindication to a block; I document it before deciding. Disease
   • Relaxants titrated to a nerve stimulator; cisatracurium has non-liver elimination.
   • He will need more opioid afterwards; multimodal analgesia with regular scoring. After surgery

5. Crisis

   On day two he is tremulous, sweating and seeing insects on the wall. HR 132, BP 178/104, temperature 38.6°C. What do you do?

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   • Severe withdrawal heading to delirium tremens, an emergency with mortality up to 10%. Crisis
   • I exclude mimics: hypoxia, hypoglycaemia, sepsis, pain, and a head injury from his fall.
   • IV benzodiazepine boluses titrated to calm; benzodiazepines, not an antipsychotic alone.
   • Thiamine again, and I look for confusion and ataxia of Wernicke's.
   • Beta-blocker for his tachycardia and hypertension; magnesium and potassium corrected.
   • If he seizes: midazolam 1–5 mg IV and protect his airway.
   • ICU if he needs repeated large doses or airway protection. After surgery