No Evidence for Administration of Thiamine Before Glucose to the Comatose Patient

Report By: Kara Cardenas - Resident EM Physician
Search checked by Jeffrey S. Jones MD - Research Director, EM Residency Program
Institution: Grand Rapids Medical Education Partners/ Michigan State University College of Human Medicine
Date Submitted: 15th July 2006
Last Modified: 25th May 2010
Status: Blue (submitted but not checked)

Three Part Question

In [comatose adults who present to the emergency department] is [administration of thiamine necessary before glucose] for [prevention of Wernicke Korsakoff Syndrome]

Clinical Scenario

A 45 year old homeless man presents to the emergency department after he was found lying on a park bench. Glasgow Coma Scale is 5, so he is intubated. Prior to administration of intravenous fluids, you consider whether you should administer thiamine to prevent Wernicke Korsakoff syndrome.

Search Strategy

Medline 1950-05/10 using OVID interface, Cochrane Library (2010), PubMed clinical queries

[(exp thiamine/therapeutic use OR exp vitamin B complex/therapeutic use) AND (exp Wernicke encephalopathy/). LIMIT to human AND English.

Search Outcome

158 papers were found, none of which supported the need to precede glucose administration with thiamine to prevent Wernicke encephalopathy.

Comment(s)

Wernicke's encephalopathy is a syndrome characterised by ataxia, ophthalmoplegia, confusion, and impairment of short-term memory. It is caused by inadequate intake or absorption of thiamine (vitamin B1). Alcoholics are particularly at risk, but it may also occur with thiamine deficiency states arising from other causes, particularly in patients with such gastric disorders as carcinoma, chronic gastritis, Crohn's disease, and repetitive vomiting, particularly after bariatric surgery. Several cases have been reported in which acute Wernicke's encephalopathy was precipitated by the administration of glucose-containing solutions prior to the administration of thiamine. Although there is no direct evidence to support the need to precede glucose administration with thiamine, the established biochemical link between the two substances suggests that their contemporaneous administration is desirable.

Clinical Bottom Line

Based on the available evidence, we cannot advocate any delay in glucose delivery while awaiting thiamine administration. However, if the first provider fails to give parenteral thiamine at the time of glucose administration, thiamine may be forgotten.