Case: 48 years old male with history of alcohol abuse is admitted to ICU with community-acquired pneumonia. Patient is found to be hypoglycemic with 50 mg/dL on admission. Thiamine and dextrose are ordered. Pharmacy informed that it would take about 15 minutes to get thiamine. The next step? (select one)
A) Administer dextrose due to severe hypoglycemia
B) Wait for thiamine to avoid Wernicke's encephalopathy
Answer: A
Although it is true that ideally, thiamine should be administrated before dextrose in patients with alcohol abuse to avoid the risk of Wernicke's encephalopathy, it is highly over-rated. The evidence in this regard is very weak. The neurological risk in this patient from hypoglycemia outweighs any other risk. It would not be wise to wait for thiamine.
This question highlights that conventional practices based only on isolated incidents (weak evidence) should not cloud the clinician's judgment (see reference#2).
#neurology
#alcohol-abuse
References:
1. Schabelman E, Kuo D. Glucose before thiamine for Wernicke encephalopathy: a literature review. J Emerg Med 2012; 42:488.
2. Hack JB, Hoffman RS. Thiamine before glucose to prevent Wernicke encephalopathy: examining the conventional wisdom. JAMA 1998; 279:583.
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