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Three Part Question

Do [patients with acute uncomplicated alcohol intoxication] [recover and leave the Emergency Department faster] when [administered intravenous fluids compared to patients who are not administered intravenous fluids]?

Clinical Scenario

A 35 year old man has been out drinking alcohol all night. He is brought in to the Emergency Department in the early hours of the morning after having fallen asleep in the back of a taxi and appears extremely intoxicated. Clinical examination is otherwise unremarkable and reveals no external evidence of a head injury. His observations are all within the normal range. You are asked to prescribe some intravenous fluids to “flush out the alcohol” but the nursing staff and wonder whether it will actually make any difference to his recovery and discharge.

Search Strategy

Medline 1946 to Week 20 2015 using OVID interface
(ethanol.ti,ab AND intravenous.ti,ab AND intoxicat*.ti,ab) OR (ethanol.ti,ab AND clearance.ti,ab) LIMIT to English language AND human

Search Outcome

401 papers were identified. Five were relevant to the clinical question and 396 were disregarded.

The references in the four identified papers were also then reviewed but did not reveal any more relevant papers.

Citations of the four identified papers were checked in Google Scholar revealed two more relevant papers.

Six papers in total were included.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Siegfried RS Perez, Gerben Keijzers, Michael Steele, Joshua Byrnes, Paul A Scuffham 2013 Australia	144 prospectively enrolled non-consecutive patients aged 18-50 years, presenting to two Emergency Departments (one tertiary centre and one urban general hospital) in Australia between October 2011 and May 2012, with acute alcohol intoxication were enrolled into the study. Only patients with uncomplicated alcohol intoxication were included. They were randomised to groups given 20ml/kg intravenous 0.9% saline and observation or observation alone. A structured pathway was implemented comprising of baseline blood tests, intravenous cannulation, serial breath alcohol testing and intoxication scores for both groups. Both groups were similar in baseline characteristics.	Single blind RCT	Emergency Department length of stay (EDLOS)	Intravenous normal saline made no significant difference to EDLOS compared to the observation only group.	There was no placebo arm. Therapies were not blinded from ED staff. Recruitment was not from consecutive patients. The study was insufficiently powered to confirm or deny the statistical significance of the small differences seen in secondary outcomes.
			Observational Assessment of Alcohol Intoxication score (OAAI)	Intravenous normal saline made no significant difference to OAAI scores at 2 hours or discharge compared to the observation only group.
			Breath alcohol level (BAL)	Intravenous normal saline made no significant difference to BAL scores at 2 hours or discharge compared to the observation only group.
			General state of intoxication 5 point scale	Intravenous normal saline made no significant difference to general intoxication scales at 2 hours.
			Cost	The administration of intravenous fluids cost an additional A$31.92 per patient.
Hindmarch PN, Land S, Wright J 2012 England	No patients A survey of 136 Emergency Physicians in North East England to establish current practice regarding intravenous fluid administration in patients with acute alcohol intoxication	Expert opinion	Use of intravenous fluids in patients with acute alcohol intoxication without head injury	The majority (73%) of Emergency Physicians questioned use intravenous fluids in the management of acute alcohol intoxication. The majority (52%) would also use intravenous fluids in the management of patients with evidence of a concurrent head injury.	Survey of current opinion and practice only. Low level of evidence.
Li J, Mills T, Erato R 1999 USA	10 healthy volunteers were prospectively enrolled, aged 23-36 years. 5 were male and 5 were female. Breath alcohol levels were taken prior to and at 20 minute intervals, after an oral alcohol bolus based on bodyweight, for a total of 4-6 hours until approximately 12 samples were taken. This was repeated after 4 days although 1L of intravenous 0.9% saline was administered directly after the alcohol bolus on the second occasion.	Crossover study	Serial breath alcohol levels	There was no change in alcohol clearance rates in the subjects with or without intravenous fluids.	Although ethics of research were considered upon designing the study. Institutional ethical approval was not obtained. There was a small sample size although a crossover study design was used to double the amount of data generated and allowed perfectly matched controls. Subjects were all healthy euvolaemic volunteers while patients presenting to the Emergency Department are often dehydrated or have concurrent medical problems. Chronic alcoholics were excluded. There was no objective clinical measure of intoxication.
			Subjective intoxication levels	There was no change in subjective intoxication levels after the administration of intravenous fluid.
Toups VJ, Pollack CV, Jr., Carlton FB 1992 USA	19 healthy volunteers were prospectively enrolled, age 21-41 years. 14 were male and 5 were female. They fasted for 6 hours and then drank beer until clinically inebriated. Breath alcohol levels were taken. They were cannulated with a wide bore peripheral intravenous line and had 15 minutes of intravenous fluids at a “wide open” rate. A second blood alcohol level was then taken.	Cohort study	Blood alcohol levels	There was no change in blood alcohol levels before and after 15 minutes of intravenous normal saline.	Subjects were all healthy euvolaemic volunteers while patients presenting to the Emergency Department are often dehydrated or have concurrent medical problems. There was no control arm to compare alcohol levels without intravenous fluid administration although one might assume that without intravenous therapy these would not change significantly within 15 minutes. Subjects were only given 15 minutes of intravenous fluid therapy no matter what volume was administered. This was done to reflect practice in a pre-hospital setting but does not necessarily reflect practice in an Emergency Department setting. Blood alcohol levels were the primary outcome measure rather than a clinical change.
Gershman H 1992 USA	101 prospectively enrolled patients, with a mean age of 41.2 years, presenting to the ED with acute alcohol intoxication were studied. They had at least three sequential blood tests for and analysed for serum alcohol levels. Alcohol clearance curves were plotted. 41 patients were administered intravenous fluids while 60 patients had none. Patients were given fluids in a random basis with between 0 and 2000ml (mean 259ml) being administered.	Cohort study	Serial blood alcohol levels	Blood alcohol levels fell linearly in all patients. There was no difference in alcohol clearance with or without intravenous fluids.	Alcohol clearance rate regardless of intravenous fluids was the primary endpoint as an initial paper published in 1991 (Gershman H, Steeper J. Rate of clearance of ethanol from the blood of intoxicated patients in the emergency department. The Journal of emergency medicine 1991;9(5):307-11) made no reference to whether intravenous fluids had been administered. This further letter to the editors was published in 1992 which released information regarding the administration of intravenous fluids. Hetrogenous study population with a bias towards black people and males. Data on the background alcohol use of these patients is not presented. Chronic alcohol abusers are included mixed with patients with acute intoxication. Randomisation method of patients to the intravenous fluid or no intravenous fluid groups was not explained. Method by which the volume of intravenous fluid to be administered was not explained. Enrolled patients were non-consecutive. More patients were enrolled while the authors were on duty than other physicians. There is therefore likely to have been some selection bias. Patients discharged or transferred out of the ED quickly (prior to three blood samples being taken) were not included. Uncooperative patients and those lacking venous access were not included. The number of patients excluded on this basis is unknown.

Comment(s)

Gershman et al have demonstrated that blood alcohol clearance is linear (i.e. follows zero order kinetics and is therefore substrate independent). Despite this, many Emergency Physicians routinely administer intravenous fluids to patients with acute uncomplicated alcohol intoxication.

Clinical Bottom Line

There is no evidence that intravenous fluids accelerate the recovery or discharge of patients with uncomplicated acute alcohol intoxication presenting to the ED.

References

1. Perez SR, Keijzers G, Steele M, et al. 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 2013;25(6):527-34
2. Hindmarch PN, Land S, Wright J Emergency physicians' opinions on the use of intravenous fluids to treat patients intoxicated with ethanol (alcohol): attitudes of emergency medicine physicians in the North East of England European Journal of Emergency Medicine 2012;19(6):379-83
3. Li J, Mills T, Erato R Intravenous saline has no effect on blood ethanol clearance. The Journal of emergency medicine 1999;17(1):1-5
4. Toups VJ, Pollack CV, Jr., Carlton FB Blood ethanol clearance rates. The Journal of emergency medicine 1992;10(4):491-3
5. Gershman H Letters to the editor. The Journal of emergency medicine 1992;10:492-93