In January's edition of EMA was this interesting little study on the use of normal saline IVT for alcohol intoxication:
Perez, S. R., Keijzers, G., Steele, M., Byrnes, J. and Scuffham, P. A. (2013), Intravenous 0.9% sodium chloride therapy does not reduce length of stay of alcohol-intoxicated patients in the emergency department: A randomised controlled trial. Emergency Medicine Australasia, 25: 527–534.
I.v. 0.9% sodium chloride (normal saline) is frequently used to treat ED patients with acute alcohol intoxication despite the lack of evidence for its efficacy.
The study aims to compare treatment with i.v. normal saline and observation with observation alone in ED patients with acute alcohol intoxication.
A single-blind, randomised, controlled trial was conducted to compare a single bolus of 20 mL/kg i.v. normal saline plus observation with observation alone. One hundred and forty-four ED patients with uncomplicated acute alcohol intoxication were included. The study was conducted in one tertiary and one urban ED in Queensland, Australia. Primary outcome was ED length of stay (EDLOS). Secondary outcomes were treatment time, breath alcohol levels, intoxication symptom score, level of intoxication and associated healthcare costs.
Both groups were comparable at baseline: blood alcohol content (BAC) was similar between treatment and control groups (0.20 % BAC vs 0.19 % BAC, P = 0.44) as were initial intoxication symptom scores (22.0 vs 22.3, P = 0.90). Both groups had a similar EDLOS (287 min vs 274 min, P = 0.89; difference 13 min [95% CI −37–63]) and treatment time (244 min vs 232 min, P = 0.94; difference 12 min [95% CI −31–55]). Change of breath alcohol levels, intoxication score and level of intoxication were not significantly different between the two groups. Patients in the treatment group had an additional healthcare cost of A$31.92 compared with control.
I.v. normal saline therapy added to observation alone does not decrease ED length of stay compared with observation alone. Intoxication symptom scores and general state of intoxication were similar in both groups. The present study suggests that either approach is reasonable, but observation alone might be preferred as it is less resource intensive.
I'll put the main outcomes of the trial first, then outline the methodology a little bit more.
There is no evidence that in alcohol-intoxicated patients a bolus of i.v. normal saline administration, together with observation, delivers better patient-oriented outcomes than observation alone.
This study of 144 patients presenting to ED with acute, uncomplicated alcohol intoxication demonstrated that a 20ml/kg bolus of normal saline in patients presenting to ED needing observation for simple alcohol intoxication did not make any difference to the length of stay in ED (primary outcome). In addition there was no difference in secondary outcomes:
- Treatment time (from first seen by clinician to discharge)
- Change in intoxication score using the OAAI tool used in the World Health Organization Collaborative Study on Alcohol and Injuries
- Change in subjective level of intoxication according to the treating nurse
- Change in blood or breath alcohol levels
In addition, the treatment group used A$31.92 more per presentation. This difference is attributed to the cost of giving saline and the difference in staff time. The authors estimate that if the routine laboratory tests used in the trial were also avoided, then they could have saved an additional A$62.94 per patient.
Design and population
This was a single-blinded (data analysis), two-centre (tertiary and urban hospitals), randomised trial of patients aged 18 - 50 presenting with uncomplicated alcohol intoxication. Pregnant, aggressive and intellectually impaired patients and complicated presentations (head injury, concomitant condition requiring further investigation or treatment, airway compromise) were excluded. Ethics approval was given for waiver of consent with the option to withdraw consent after treatment.
The primary endpoint was ED length of stay (LOS) from triage to discharge. Discharge time data were collected on a data collection sheet. Discharge was at the discretion of the treating doctor per local protocols (GCS 15, ambulant, no ongoing concerns, responsible escort, or left before treatment complete).
Secondary endpoints were:
- Treatment time from first seen by treating doctor or nurse to "ready for discharge"
- Absolute, percentage and rate of change in an objective alcohol intoxication scale at 2 hours and discharge (adapted from the OAAI tool used in the World Health Organization Collaborative Study on Alcohol and Injuries)
- Change in general state of intoxication assessed by the treating RN on a 5-point scale from very severe to not intoxicated
- Absolute, percentage and rate of change in breath alcohol level at 2 hours and discharge
Economic evaluation was performed taking into account direct resource use (IV sets, bags of saline, laboratory tests) and self-reported staff time. ED bedspace and security were not included.
The study was largely a convenience sample, based on triage nurse identification. This means that patients were missed due to clinical priorities, lack of recognition, etc. Only 144 of 425 potentially eligible patients were included, based on primary diagnosis, out of 3752 alcohol-related presentations in total.
The observation in both groups consisted of a monitored bay with oxygen saturation, blood pressure and heart rate. Hourly Glasgow Coma Scale measurements and respiratory rate observations were performed according to hospital protocol. This is more than we do as basic observation.
There was also some incomplete data (breath and blood alcohol, intoxication scores), and no reporting of adverse events or follow up (eg IV line assoc infections, etc).
Do we still give routine IVT to intoxicated patients? Does it reduce hangover symptoms, and therefore represent a better standard of care? Does it encourage earlier wakefulness and mobilisation by filling the bladder quicker?