David H. Knott

The Effect of Alcohol on Fluid and Electrolyte Metabolism

Since the time that the technique of fermentation was learned by prehistoric man, alcohol has been used primarily for its cerebral manifestations, often with unfortunate physiologic consequences. Undoubtedly, a common clinical observation on which Shakespeare commented in Act II, Scene iii of Macbeth was that the drinking of alcoholic beverages promotes an increased flow of urine. Despite this observation, it is of interest how clinical impressions of heavy drinkers changed drastically throughout the history of medicine. During the eighteenth and nineteenth centuries and until 1938, most persons who ingested large quantities of alcohol were described as being “dropsical” (Coffey, 1966). Indeed, between 1718 and 1751 in London, deaths from “dropsical conditions” reached an unprecedented level. It should be noted that this was a general term used for any abnormal amount of fluid in cellular tissue or body cavity, and most forms were associated with excessive drinking. When the mortality rate fell rapidly, physicians at this time attributed the decline to a marked attenuation of public drunkenness. In addition to general edematous states as a result of alcohol ingestion, cerebral edema has been frequently described (Sutton, 1813; Snowden, 1820; Hayward, 1822). Postmortem investigations of patients who died from delirium tremens revealed markedcongestion and turgidity of cerebral blood vessels, turgidity of dural sinuses, together with an increase in subarachnoid and ventricular quantities of cerebrospinal fluid. When the dura was opened, marked quantities of serous fluid were discharged (Sutton, 1813; Snowden, 1820; Hayward, 1822). Treatment was directed at dehydrating the patient because of the “dropsical conditions,” and such techniques as conservative blood letting, purgation (Sutton, 1813; Hayward, 1822), emetics (Klapp, 1817; Snowden, 1820), and hot tub baths (Hayward, 1822; Wright, 1830) were used. Spinal drainage was often used in an attempt to relieve the cerebral edema (Steinbach, 1915).

Decision for alcohol detoxication: a method to standardize patient evaluation

We have presented a tested method of evaluation of the patient with acute alcohol intoxication and/or abstinence syndromes, which we recognize needs further modification and refinement. However, we wish to encourage continued development and standardization of an evaluation instrument that ultimately can become widely accepted. This should reduce the current confusion concerning the diagnosis, extent, and severity of the acute phase of alcohol dependence. If this can be accomplished, the questions (and the controversy) of drug vs non-drug and medical vs nonmedical treatment become moot; rather, a continuum of care will exist which is based on meaningful use and interdisciplinary communication of symptom severity as a foundation for rational treatment approaches.

Changes in Cardiovascular Activity as a Function of Alcohol Intake

If one would truly appreciate the classic description of alcohol as “man’s psychological blessing and physiological curse” then much of the scientific mysticism surrounding this drug could be removed. The deleterious effects of alcohol oil the heart and blood vessels have long been recognized, yet recent and current medical literature tends to promote the “discretionary” use of ethanol in the treatment of various cardiovascular disorders such as angina pectoris, hypertensive cardiovascular disease, and obliterative vascular disease.

Acute Withdrawal From Alcohol

Acute alcoholic withdrawal is a common clinical problem, and delirium tremens is its most severe form. Symptoms of withdrawal must be evaluated carefully and treated aggressively. The severity of the withdrawal syndrome cannot always be predicted on the basis of quantity or duration of alcohol ingestion. Sedation must be handled with extreme care, and special attention to fluid and electrolyte balance is of the utmost importance.

The use of plasma and urine osmolality in evaluating the acute phase of alcohol abuse

Increasing emphasis on managing acute alcohol- and drug-induced medical-psychiatric conditions demands that rapid screening diagnostic procedures be available to the physician. Since it obviously is useful to have some idea of the blood alcohol concentration (BAC), the feasibility of using plasma osmolality as a reflection of BAC is discussed. The increment in plasma osmolality caused by a unit increase in plasma alcohol is linear, eg, a rise in plasma osmolality of 21.7 mOsm/kg H2O reflects a 100 mg/100 ml increase in plasma alcohol. Since plasma osmolality can be determined rapidly and easily, it can yield useful information and often preface a more thorough biochemical examination. Furthermore, concomitant measurement of urine osmolality can be an indicator of the state of hydration in the acute alcoholic condition. Obtaining an estimate of BAC (by measuring plasma osmolality) allows the physician to correlate signs and symptoms with BAC and to more skillfully plan the psychopharmacologic approach to the patient.