Alcohol

• 3–36 hr: minor symptoms similar to other depressants
• 6–48 hr: withdrawal seizures
• 12–48 hr: alcoholic hallucinosis (usually visual)
• 48–96 hr: delirium tremens (DTs) in 5% of cases
• Treatment: benzodiazepines

• 1st line: benzodiazepine (eg. lorazepam)
• if agitated due to poor analgesia: morphine
• if postoperative delirium only: haloperidol

• Life-threatening alcohol withdrawal syndrome that peaks 2–4 days after last drink.
• Characterized by autonomic hyperactivity (eg, tachycardia, tremors, anxiety, seizures), electrolyte disturbances, respiratory alkalosis.
• Classically occurs in hospital setting (eg, 2–4 days postsurgery) in alcoholics not able to drink as inpatients.
• Treatment: long half-life benzodiazepines (eg, chlordiazepoxide, lorazepam, diazepam).

• IM, IV (off-label route) (lactate injection): 2 to 10 mg; repeat dose every ≥15 minutes until acute symptoms are controlled; once acute symptoms are controlled, may repeat every 0.5 to 6 hours as needed; up to 30 mg/day.
• Oral: 2 to 10 mg; repeat dose every 6 hours as needed; up to 30 mg/day. A lower initial dose of 0.5 to 1 mg may be sufficient for some patients.

The typical composition of a banana bag is 1 liter of normal saline (sodium chloride 0.9%) with:

• Thiamine 100 mg
• Folic acid 1 mg
• Multivitamin for infusion (MVI), 1 ampule
• Magnesium sulfate 3 g

The solution is typically infused over four to eight hours. The yellow color comes from folic acid and the multivitamin.

Banana bags are often prescribed for alcoholics. Chronic alcoholism can lead to significant lack of thiamine, potentially causing Wernicke–Korsakoff syndrome. Chronic alcoholics can also suffer significant whole-body magnesium deficiencies. However, recent evidence (2016) points that the amount of thiamine in a conventional banana bag is inadequate for prophylaxis and treatment for ICU patients. The proposed regimen is 200–500 mg IV thiamine every eight hours for the first day of admission. Less evidence exists for the use of magnesium and folic acid, for which a less radical change in dosage is proposed. No evidence for the use of multi-vitamins are found for alcoholics.

• Caused by vitamin B1 defciency. Triad of confusion, ophthalmoplegia, ataxia (Wernicke encephalopathy). May progress to irreversible memory loss, confabulation, personality change (Korsakof syndrome). Symptoms may be precipitated by giving dextrose before administering vitamin B1 to a patient with thiamine deficiency. Associated with periventricular hemorrhage/ necrosis of mammillary bodies.
• Treatment: IV vitamin B1.