Underuse of Thiamine in Patients With Alcohol Use Disorder in the Intensive Care Unit
Highlights
- Wet and Dry Berry Berry
Summary:
There are two types of Guillain-Barre cases. One is gastrointestinal berry berry where patients present with profound lactic acidosis with lactates. The other presentation is kind of the cardiovascular berry bberry where they can get high output cardiac failure and often a high lactic Acidosis. They can present with edema or without edema and that kind of got the terms of wet and dry berry b berries.
Transcript:
Speaker 1
So all of those cases I described which is just a small handful three or four were all labeled as Guillain-Barre cases at first. So that's an interesting very rare but interesting presentation. Then the other presentation is kind of the cardiovascular berry berry where they can get high output cardiac failure and often a high lactic acidosis and they can present with edema or without edema and that kind of got the terms of wet and dry berry berry. Sometimes dry berry berry is kind of interchanged with the neurotic but if you look back in the early literature the wet and dry basically just differentiated people who were presenting with edema or without edema in that high output state. So those are kind of the classics also described a long time ago in the annals of internal medicine was a potential new variant which I termed gastrointestinal berry berry and it was fascinating but you saw patients present with profound lactic acidosis with lactates, the original one was lactate of like 30 abdominal pain, nausea and vomiting and at that time this patient took them off to the operating room thinking that ballastchemia and it turned out that all he needed was intravenous diamond and his lactate cleared. Now that particular patient came back multiple times and then I was able to see a pattern in another (Time 0:07:09)
- Should We Measure Thiamine Levels or Should We Send a Transketolase?
Summary:
Some people can have lower thiamine levels but not be manifesting the clinical signs. It's never been completely correlated exactly what level of thiamine would constitute a clinical deficiency state and whatnot. For all those reasons I would say that it is a clinical diagnosis particularly with respect to the levels.
Transcript:
Speaker 2
Before we get to the article the other thing that sometimes comes up is should we measure thiamine levels or should we send a transketolase or is this just a clinical diagnosis and let's empirically give them thiamine.
Speaker 1
Two challenges. One is they take a substantial amount of time to turn around. Typically a thiamine level is a send out for most laboratories and you're not going to get a result for days or maybe even a week and by that time it's too late. The second problem is that it's never been completely correlated exactly what level of thiamine would constitute a clinical deficiency state and whatnot and there are some people who can have lower thiamine levels but not be manifesting the clinical signs. For all those reasons I would say that it is a clinical diagnosis particularly with respect to the levels. Well I think it's just in general a clinical diagnosis. I guess the one thing I was going to say is that every now and then you'll see someone get an MRI not thinking about Wernickeys and they'll actually see what you can see there is classic bilateral thalamic lesions even more so than the mammillary body atrophy and in that case that's another case where it kind of should ring a bell and say this is probably Wernickeys but the levels themselves is too delayed in terms of getting that information back and I would argue that it's largely a clinical diagnosis. (Time 0:10:19)
New highlights added February 26, 2023 at 6:11 PM
- Dose of 100 Milligrams
Summary:
In World War II when there was in the Japanese prison camps and people were deprived of thiamine then developed some of these symptoms all they could get was a few milligrams to the soldiers. So you know it's really unclear. I guess what I generally say is that if someone doesn't have a manifestation of Wernicke's or other conditions we should not give them this drug.
Transcript:
Speaker 1
Well he said well you know when I was first putting this together I needed to give a high dose of thiamine so I figured 60 milligrams would be a good dose and you know we went from there. I said well 60, what about 100? He's like oh yeah the medical student I was with thought that 60 would be hard to remember so let's just go with 100. So I said okay. So that's where the original dose of 100 milligrams came from. It basically just was kind of made up to kind of have a high dose. And so then you move forward to this dose of in Europe they started giving 500 milligrams and there was literally at the time there's been more now but there's a case report that said well 100 wasn't good enough 500 might have helped in this case. So then the theory was well 500 milligrams is better to cross the blood brain barrier we can kind of go with that number. But the reality is that the dose is actually kind of unclear. In World War II when there was in the Japanese prison camps and people were deprived of thiamine then developed some of these symptoms all they could get was a few milligrams to the soldiers and that even seemed to help them. So you know it's really unclear. I guess what I generally say is that if someone doesn't have a manifestation of Wernicke's or (Time 0:21:10)
- Dosage of Wernicke's
Summary:
In World War II when there was in the Japanese prison camps and people were deprived of thiamine then developed some of these symptoms all they could get was a few milligrams to the soldiers. So you know it's really unclear. I guess what I generally say is that if someone doesn't have a manifestation of Wernicke's or is not in you know clear thiamine deficiency manifestation the 100 milligrams seems to be sufficient recognizing the limitations of we didn't do pharmacocalytic kinetic and all that stuff. But I will just you know have the humility to say that this dosage is really you know there's a lot of unknowns about what the correct dose is.
Transcript:
Speaker 1
And so then you move forward to this dose of in Europe they started giving 500 milligrams and there was literally at the time there's been more now but there's a case report that said well 100 wasn't good enough 500 might have helped in this case. So then the theory was well 500 milligrams is better to cross the blood brain barrier we can kind of go with that number. But the reality is that the dose is actually kind of unclear. In World War II when there was in the Japanese prison camps and people were deprived of thiamine then developed some of these symptoms all they could get was a few milligrams to the soldiers and that even seemed to help them. So you know it's really unclear. I guess what I generally say is that if someone doesn't have a manifestation of Wernicke's or is not in you know clear thiamine deficiency manifestation the 100 milligrams seems to be sufficient recognizing the limitations of we didn't do pharmacocalytic kinetic and all that stuff. And when they do have highly suspicious or you actually think this person actually has Wernicke's it is probably worth giving a higher dose with this hypothesis that you know crosses the blood brain barrier better. But I will just you know have the humility to say that this dosage is really you know there's a lot of unknowns about what the correct dose is. The last thing I'll mention too is and I said to Dr. (Time 0:21:38)
- Dosage of Wernicke's
Summary:
In World War II when there was in the Japanese prison camps and people were deprived of thiamine then developed some of these symptoms all they could get was a few milligrams to the soldiers and that even seemed to help them. So you know it's really unclear. I guess what I generally say is that if someone doesn't have a manifestation of Wernicke's or is not in you know clear thiamine deficiency manifestation the 100 milligrams seems to be sufficient recognizing the limitations of we didn't do pharmacocalytic kinetic and all that stuff.
Transcript:
Speaker 1
In World War II when there was in the Japanese prison camps and people were deprived of thiamine then developed some of these symptoms all they could get was a few milligrams to the soldiers and that even seemed to help them. So you know it's really unclear. I guess what I generally say is that if someone doesn't have a manifestation of Wernicke's or is not in you know clear thiamine deficiency manifestation the 100 milligrams seems to be sufficient recognizing the limitations of we didn't do pharmacocalytic kinetic and all that stuff. And when they do have highly suspicious or you actually think this person actually has Wernicke's it is probably worth giving a higher dose with this hypothesis that you know crosses the blood brain barrier better. But I will just you know have the humility to say that this dosage is really you know there's a lot of unknowns about what the correct dose is. The last thing I'll mention too is and I said to Dr. Adams at the time and then once a day dosing he said oh I had no idea I just went with that. But now we kind of know that the half-life is actually quite short so it's probably worth giving thiamine two or three times a day. Again in the patients who you have an actual manifestation of thiamine deficiency disorder. (Time 0:22:04)