A recent study published in the Journal of the American College of Surgeons provides a detailed analysis of the impacts of alcohol withdrawal syndrome (AWS) and delirium tremens (DT) on surgical patients, underscoring the significant associations that these conditions have with worse outcomes — including mortality — and higher healthcare costs.

The study, led by Timothy Pawlik, MD, professor and chair of the Department of Surgery at The Ohio State University, Columbus, Ohio, used a large, nationwide dataset to define the incidence of AWS in a broad surgical population, identify key risk factors, and quantify the clinical and financial burdens on patients and health systems associated with adverse outcomes from unidentified AWS.

The study’s findings highlight the importance of preoperative screening for alcohol use, especially in the patient populations whose demographic characteristics index the highest with alcohol use disorder (AUD), in order to mitigate, or at least properly diagnose and prepare for, side effects, should they arise. It’s a call to action for healthcare systems and providers to implement standardized screening and management strategies to improve patient care and optimize resource utilization.

Pawlik said it’s easier if they identify a patient with alcohol abuse disorder before surgery. If the procedure is elective and there is no urgency, “then the focus may be on, ‘Can we work on your drinking, get you in a better place, get you sober, then we’ll do your operation?’” Pawlik said.

Often, however, the doctor doesn’t know about the alcohol abuse until after the surgery.

“They get agitated, they get tachycardic, their heart rate’s up, and then we’re faced with this alcohol withdrawal syndrome in the hospital. At that point, we treat it medically. We do what we can to avoid them from going into DT,” Pawlik said.

Understanding the Challenge: Alcohol Withdrawal in Surgical Care

AWS is a complex and potentially life-threatening condition that occurs when a person with AUD abruptly stops or reduces their alcohol consumption. In the surgical setting, the physiologic and/or psychological stress of a major operation can trigger or exacerbate withdrawal symptoms. Pawlik noted that many AWS symptoms — which can range from anxiety and tremors to more severe manifestations like seizures and DT and include quantifiable issues that appear in lab results such as electrolyte imbalances — are also common postoperative side effects. In many cases, these symptoms mirror those of the underlying conditions for which patients are being treated.

“The potential effects are really systemic in nature — they can affect many different aspects of the postoperative recovery and can be hard to distinguish sometimes from other clinical scenarios,” Pawlik said.

For example, you can see hypokalemia (low potassium), hypomagnesemia (low magnesium), hyponatremia (low sodium levels), and even low phosphorus levels, said Pawlik. Other symptoms could be confusion, anxiety, an elevated heart rate, or maybe a patient’s electrolyte levels could be a bit off. “But we always have a differential diagnosis, so we’re always thinking, ‘what could this be?’ And it could be a number of different things,” he said.

As noted above, if the treating clinicians know that a patient has AUD, they can treat it before addressing the surgical matter, if the latter is not emergent, according to Pawlik. Alternatively, if the surgical issue at hand is actively jeopardizing the patient’s health, then the team is prepared to mitigate the potential side effects of AWS in the postoperative hospitalization period and are on high alert to spot any breakthrough problems. Either way, the team can also call in ancillary hospital resources, like behavioral health and social work, to assist with a posthospitalization recovery plan that incorporates the patient’s needs from a holistic standpoint.

Study Mechanisms, Incidence, and Patient Characteristics

Earlier research had established a link between AWS and poor surgical outcomes, but these studies largely examined specific patient populations like trauma or spine surgery patients. This new study made progress toward bridging that gap, providing a comprehensive, nationwide analysis across a wide range of major surgical procedures.

Pawlik and his research team utilized data from the National Inpatient Sample — a large, representative database of hospital stays — to analyze the records of 3 million adult patients who underwent major surgery between 2016 and 2019. For the purposes of this study, major surgical procedures were defined as those with a high risk for morbidity, including colectomy, coronary artery bypass grafting, esophagectomy, and pancreatectomy, among others. By employing validated International Classification of Diseases, 10th Revision codes, the researchers identified patients with and without AWS and then evaluated a range of outcomes, including inhospital mortality, complications, length of stay, and hospitalization costs.

Among the 3,003,140 surgical patients included in the analysis, 16,504 were diagnosed with AWS, with a significant subset of 6591 progressing to DT. This incidence is low on a percentage basis but represents a substantial number of patients nationally and highlights a critical area for intervention.

The study identified several key demographic and socioeconomic factors associated with a higher risk of developing AWS, painting a clear picture of the patient population most vulnerable to this complication; it was shown to affect overwhelmingly male patients with a median age in their early 60s. The study also revealed a strong association with socioeconomic factors because patients with AWS were more likely to have Medicaid as their insurance or be self-paying and were disproportionately represented in the lowest income quartile. This underscores the relationship between societal factors and alcohol use, as well as the potential for disparities in access to care and addiction resources.

The study further characterized the AWS patient cohort as having a higher comorbidity burden. They were also more likely to have a history of drug abuse disorders and mental health illnesses, emphasizing the complex and often co-occurring nature of substance use and psychiatric conditions. The findings also noted that AWS was more frequent among patients undergoing emergent procedures and those admitted on weekends, suggesting that the urgency and timing of care may play a role in both the diagnosis and severity of the condition.

The Clinical and Financial Impact: Worse Outcomes and Higher Costs

Patients who developed AWS experienced significantly worse clinical results across the board, even after controlling for a multitude of confounding variables through advanced statistical methods.

The risk for postoperative complications was substantially higher among the AWS cohort. After adjustment, AWS was independently associated with a 37% increased risk for any postoperative complication. The risk was particularly pronounced for specific complications, with a 2.44-fold increased risk for respiratory failure and a 1.61-fold increased risk for sepsis. These findings point to the systemic physiologic toll that AUD takes on the human body, said Pawlik.

Prior studies suggested that patients with AWS are at higher risk for pneumonia and respiratory issues, and they may have a more compromised immune function, Pawlik said.

“In our current work, we noted that patients with alcohol withdrawal syndrome had a twofold higher risk of experiencing respiratory complications, and then other risks like stroke, sepsis, or infection were also significantly higher — like 60-70% higher among patients who had AWS,” he said. “It can affect many different aspects of the postoperative recovery.”

Inhospital mortality was also a major concern. While AWS alone showed a trend toward increased mortality, the risk was statistically significant and substantially higher for patients who developed DT. These individuals had a 40% higher risk for death than non-AWS patients. This highlights the severity of DT and its association with profound autonomic dysregulation and cardiovascular instability.

The financial and logistical burden was equally significant. Patients with AWS had a median hospital stay of 11 days vs just 6 days for non-AWS patients. This extended stay was associated with a dramatic increase in healthcare costs. The adjusted hospitalization cost for a patient with AWS was $10,030 higher, contributing to an estimated national excess cost of $165.6 million during the study period. For patients with AWS complicated by DT, the costs were even higher, with an adjusted increase of over $15,000 per patient.

The Need for Standardized Perioperative Care

While this study presents important large-scale, nationwide statistics on the effects of AWS in surgical cases, its authors also advocate for a shift in clinical practice to include standardized perioperative screening for AWS risk.

One of the main goals of the paper is highlighting the need for more standardized screening for AUD, along with earlier risk stratification and targeted withdrawal management strategies for identified patients “because what the data suggests is that if we don’t identify this and we don’t treat this appropriately, patients will be at risk for adverse outcomes after major surgical operations,” Pawlik said.

He went on to underscore the extremely high risks surrounding the subset of patients who progress to DT. Preventing that complication from occurring is one of the most important aspects of being able to identify AUD, according to Pawlik.

It can be difficult to differentiate the side effects of AWS from other clinical scenarios, Pawlik said. Some may manifest increased heart rate and agitation, while others may present with electrolyte imbalances. “Unless you’re specifically thinking, ‘Could this be alcohol withdrawal?’ we may pursue other possible etiologies of those things. If you’re not thinking about it, then you can’t appropriately address it and treat it,” said Pawlik. Another interesting finding in the paper was that adverse outcomes were especially high among patients who had DT, he also said.

The study team noted that the risk factors their research identified — such as younger male patients, those with Medicaid insurance, and individuals undergoing emergent surgery — can serve as a guide for clinicians to prioritize screening efforts. The integration of validated tools, like the AUDIT-C and the CIWA-AR, into routine preoperative evaluations could help identify at-risk patients, allowing for the implementation of targeted management strategies.

AUDIT-C stands for Alcohol Use Disorders Identification Test, and the C indicates Consumption, Pawlik explained. He said that this test is a three-question screening tool that focuses on identifying individuals who may be drinking at risky or hazardous levels; it is a patient self-assessment that typically asks the frequency of alcohol consumption, the number of drinks consumed on a typical drinking day, and how often the patient binge drinks, where binge drinking is defined as six or more drinks on any one occasion.

The CIWA-AR is the Clinical Institute Withdrawal Assessment for Alcohol Withdrawal, a provider assessment made in a clinical setting; it is a 10-item assessment used to evaluate the severity of alcohol withdrawal symptoms and includes items like tremors, anxiety, nausea, vomiting, agitation, and visual disturbances. At the end, the CIWA-AR assigns a score to each one to determine the overall withdrawal severity.

Pawlik said that family members, other loved ones, or friends can be included in the assessment to ensure that the patient is accurately reporting their habits. However, probing for information should be done in a manner that reinforces that the questions the practitioner asks are strictly in the best clinical interest of the patient.

It’s important to create an environment that is nonjudgmental because addiction is a medical problem, not a moral failure, according to Pawlik. “Just like we treat hypertension, we treat diabetes, alcohol is a medical problem,” he said. “Creating an environment where patients understand that we’re not here to judge, we’re here to help you, and in order to help you, we need to know do you drink, and how much you drink, so that that is on my radar, and I can plan appropriately.”

When clinicians can assess that there is an issue, there are established treatments to follow, according to Pawlik. For example, there are medical approaches to manage AWS using medications such as benzodiazepines, along with certain vitamins including folic acid, multivitamins, and thiamine.

On some rare occasions, “we may even allow patients to drink [alcohol] in the hospital…because our goal is to prevent them from going into alcohol withdrawal syndrome and prevent them from getting DT,” Pawlik said. “In the nonacute setting, we want to help them with rehab and alcohol cessation.”

Ultimately, the study highlights that proactively identifying and managing AWS is not only a matter of improving patient outcomes but also a crucial step in optimizing healthcare resource utilization and reducing unnecessary financial costs. By embracing a more comprehensive approach to perioperative care that addresses AUD, healthcare systems can enhance patient safety, shorten hospital stays, and provide a more holistic and effective path to recovery.