Alcohol (Ethyl)

Pronunciation

(AL koe hol, ETH il)

U.S. Brand Names

Lavacol® [OTC]

Synonyms

Alcohol, Absolute; Alcohol, Dehydrated; Ethanol; Ethyl Alcohol; EtOH

Generic Available

Yes

Canadian Brand Names

Biobase™; Biobase-G™

Use

Topical anti-infective; pharmaceutical aid; therapeutic neurolysis (nerve or ganglion block); replenishment of fluid and carbohydrate calories

Use - Unlabeled/Investigational

Antidote for ethylene glycol overdose; antidote for methanol overdose; treatment of fat occlusion of central venous catheters

Pregnancy Risk Factor

C (D per expert opinion)/X (prolonged use or high doses at term)

Pregnancy Implications

Ethanol crosses the placenta, enters the fetal circulation, and has teratogenic effects in humans. The following withdrawal symptoms have been noted in the neonate following exposure to ethanol during pregnancy: Crying, hyperactivity, irritability, poor suck, tremors, seizures, poor sleeping pattern, hyperphagia, and diaphoresis. Fetal alcohol syndrome (FAS) is a term referring to a combination of physical, behavioral, and cognitive abnormalities resulting from ethanol exposure during fetal development. Since a "safe" amount of ethanol during pregnancy has not been determined, the AAP recommends those women who are pregnant or planning a pregnancy refrain from all ethanol intake. When used as an antidote during the second or third trimester, FAS is not likely to occur due to the short treatment period; use during the first trimester is controversial.

Lactation

Enters breast milk/use caution (AAP rates "compatible")

Contraindications

Hypersensitivity to ethyl alcohol or any component of the formulation; seizure disorder and diabetic coma; subarachnoid injection of dehydrated alcohol in patients receiving anticoagulants; pregnancy

Warnings/Precautions

Ethyl alcohol is a flammable liquid and should be kept cool and away from any heat source; proper positioning of the patient for neurolytic administration is essential to control localization of the injection of dehydrated alcohol (which is hypobaric) into the subarachnoid space; avoid extravasation; not for SubQ administration; do not administer simultaneously with blood due to the possibility of pseudoagglutination or hemolysis; may potentiate severe hypoprothrombic bleeding; clinical evaluation and periodic lab determinations, including serum ethanol levels, are necessary to monitor effectiveness, changes in electrolyte concentrations, and acid-base balance (when used as an antidote)

Use with caution in diabetics (ethyl alcohol decreases blood sugar), hepatic impairment, patients with gout, shock, following cranial surgery, and in anticipated postpartum hemorrhage; monitor blood glucose closely, particularly in children as treatment of ingestions is associated with hypoglycemia; avoid extravasation during I.V. administration; ethyl alcohol passes freely into breast milk at a level approximately equivalent to maternal serum level; minimize dermal exposure of ethyl alcohol in infants as significant systemic absorption and toxicity can occur.

Adverse Reactions

Frequency not defined.

Central nervous system: Disorientation, encephalopathy, flushing, sedation, seizures (rare), vertigo

Endocrine & metabolic: Hypoglycemia

Genitourinary: Urinary retention

Local: Nerve and tissue destruction

Miscellaneous: Intoxication

Mechanism of Action

When used to treat ethylene glycol or methanol toxicity, ethyl alcohol competitively inhibits their metabolism and decreases the formation of toxic metabolites.

Pharmacodynamics/Kinetics

Duration: Vd: 0.6-0.7 L/kg; decreased in women

Absorption: Oral: Rapid

Metabolism: Hepatic (90% to 98%) to acetaldehyde or acetate

Half-life elimination: Rate of elimination: 15-20 mg/dL/hour (range: 10-34 mg/dL/hour); increased in alcoholics

Excretion: Kidneys and lungs (~2% unchanged)

Dosage

Treatment of methanol or ethylene glycol ingestion (unlabeled use): Children and Adults: Absolute ethanol (86 proof = 34 g EtoH/dL)/ethyl alcohol: Note: Continue until methanol or ethylene glycol are no longer detected or <20 mg/dL and metabolic acidosis is corrected:

Oral: Note: Oral dosing is not recommended outside of a hospital setting: Initial dose: 600 mg/kg [equivalent to 1.8 mL/kg using a 43% solution]

Maintenance dose:

Nondrinker: 66 mg/kg/hour [equivalent to 0.2 mL/kg/hour using a 43% solution]

Chronic drinker: 154 mg/kg/hour [equivalent to 0.46 mL/kg/hour using a 43% solution]

Dosage adjustment for hemodialysis: Maintenance dose:

Nondrinker: 169 mg/kg/hour [equivalent to 0.5 mL/kg/hour using a 43% solution]

Chronic drinker: 257 mg/kg/hour [equivalent to 0.77 mL/kg/hour using a 43% solution]

I.V.: Initial dose: 600 mg/kg [equivalent to 7.6 mL/kg using a 10% solution]

Maintenance dose:

Nondrinker: 66 mg/kg/hour [equivalent to 0.83 mL/kg/hour using a 10% solution]

Chronic drinker: 154 mg/kg/hour [equivalent to 1.96 mL/kg/hour using a 10% solution]

Dosage adjustment for hemodialysis: Maintenance dose:

Nondrinker: 169 mg/kg/hour [equivalent to 2.13 mL/kg/hour using a 10% solution]

Chronic drinker: 257 mg/kg/hour [equivalent to 3.26 mL/kg/hour using a 10% solution]

Treatment of fat occlusion of central venous catheters (unlabeled use): Children and Adults: Dehydrated alcohol injection: I.V. (see institutional-based protocol for catheter clearance assessment, the following assessment is a general methodology): Up to 3 mL of ethanol 70% (maximum 0.55 mL/kg); the volume to instill is equal to the internal volume of the catheter

Antiseptic: Children and Adults: Liquid denatured alcohol: Topical: Apply 1-3 times/day as needed

Therapeutic neurolysis (nerve or ganglion block): Adults: Dehydrated alcohol injection: Intraneural: Dosage variable depending upon the site of injection (eg, trigeminal neuralgia: 0.05-0.5 mL as a single injection per interspace vs subarachnoid injection: 0.5-1 mL as a single injection per interspace); single doses >1.5 mL are seldom required

Replenishment of fluid and carbohydrate calories: Adults: Dehydrated alcohol infusion: Alcohol 5% and dextrose 5%: 1-2 L/day by slow infusion

Administration

Oral: Ethylene glycol or methanol poisoning: Dilute ethyl alcohol to 20% solution and administer hourly via NG tube; oral treatment is not recommended outside of a hospital setting

I.V.: Ethylene glycol or methanol poisoning: Administer as a 10% solution in D5W; initial dose should be administered over 1 hour

Treatment of occluded central venous catheter: Instill a 70% solution with a volume equal to the internal volume of the catheter; assess patency at 30-60 minutes (or per institutional protocol)

Intraneural: Separate needles should be used for each of multiple injections or sites to prevent residual alcohol deposition at sites not intended for tissue destruction; inject slowly after determining proper placement of needle; since dehydrated alcohol is hypobaric when compared with spinal fluid, proper positioning of the patient is essential to control localization of injections into the subarachnoid space

Monitoring Parameters

Antidotal therapy: Blood ethanol levels every 1-2 hours until steady state, then every 2-4 hours; blood glucose, electrolytes (including serum magnesium), arterial pH, blood gases, methanol or ethylene glycol blood levels; heart rate, blood pressure

Reference Range

Antidote for methanol/ethylene glycol: Blood ethanol level: Goal range: 100-150 mg/dL

Additional Information

Neurolytic block: Pain will occur after initial injection for a short period of time and will subside when neurolysis occurs; agent will destroy nerve and should be administered when pain is from malignant origin only; administer carefully.

Replenishment of fluid and carbohydrate calories: If the daily fluid requirement is >3 L/day, use of alcohol 5% in dextrose 5% is not recommended.

Undiluted ethanol 86 proof = 43% oral solution = 34 g ethanol/dL

I.V. solution 10% = 7.9 g ethanol/dL

Anesthesia and Critical Care Concerns/Other Considerations

Neurolytic block: Pain will occur after initial injection for a short period of time and will subside when neurolysis occurs. This agent will destroy nerve and should be administered when pain is from malignant origin only; administer carefully.

Methanol/ethylene glycol poisoning: Treatment involves inhibiting the formation of toxic metabolites by inhibiting alcohol dehydrogenase and/or urgent dialytic removal of these alcohols and their metabolites. Fomepizole and ethanol are both inhibitors of alcohol dehydrogenase and have been used to prevent toxicity. Currently fomepizole is the drug of choice because of its ease of use and lack of CNS toxicity. When ethanol is used, a target serum level of 100-200 mg/dL is maintained during treatment. Patients are treated until serum levels of the poison (ethylene glycol/methanol) are <20 mg/dL.

Dental Health: Effects on Dental Treatment

No significant effects or complications reported

Dental Health: Vasoconstrictor/Local Anesthetic Precautions

No information available to require special precautions

Mental Health: Effects on Mental Status

May cause confusion, disorientation, encephalopathy, sedation, and dizziness

Mental Health: Effects on Psychiatric Treatment

Avoid use in patients receiving psychotropic agents. Concomitant use with pychotropic agents may produce additive sedation.

Dosage Forms

Infusion [in D5W, dehydrated]: Alcohol 5% (1000 mL); alcohol 10% (1000 mL)

Injection, solution [dehydrated]: 98% (1 mL, 5 mL)

Liquid, topical [denatured] (Lavacol®): 70% (473 mL)

References

"American Academy of Pediatrics Committee on Drugs. The Transfer of Drugs and Other Chemicals into Human Milk," Pediatrics , 2001, 108(3):776-89.

"American Academy of Pediatrics. Committee on Substance Abuse and Committee on Children With Disabilities, Fetal Alcohol Syndrome and Alcohol-Related Neurodevelopmental Disorders," Pediatrics , 2000, 106 (2):358-61.

Barceloux DG, Krenzelok EP, Olson K, et al, "American Academy of Clinical Toxicology Practice Guidelines on the Treatment of Ethylene Glycol Poisoning. Ad Hoc Committee," J Toxicol Clin Toxicol , 1999, 37(5):537-60.

Barceloux DG, Bond GR, Krenzelok EP, et al, "American Academy of Clinical Toxicology Practice Guidelines on the Treatment of Methanol Poisoning. Ad Hoc Committee," J Toxicol Clin Toxicol , 2002, 40(4):415-46.

Koren G, "Drinking Alcohol While Breastfeeding. Will It Harm My Baby?" Can Fam Physician , 2002, 48:39-41.

Mokhlesi B, Leikin JB, Murray P, et al, "Adult Toxicology in Critical Care: Part II: Specific Poisonings," Chest , 2003, 123(3):897-922.

"Neonatal Drug Withdrawal. American Academy of Pediatrics Committee on Drugs," Pediatrics , 1998, 101(6):1079-88.

Pennington CR and Pithie AD, "Ethanol Lock in the Management of Catheter Occlusion", JPEN J Parenter Enteral Nutr , 1987, 11(5):507-8.

Werlin SL, Lausten T, Jessens, et al, "Treatment of Central Venous Catheter Occlusions With Ethanol and Hydrochloric Acid", JPEN J Parenter Enteral Nutr , 1995, 19(5):416-8.

International Brand Names

Biobase™ (CA); Biobase-G™ (CA)

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