1/ Alright #neuroX (?!?!)
A 78 yo man is hospitalized with sepsis, he undergoes a long hospitalization complicated by ileus and AKI requiring HD (now resolved).
He has been hospitalized 62 days.
The ICU team calls you for ?refractory delirium?
A #ContinuumCase (image mine)
A 78 yo man is hospitalized with sepsis, he undergoes a long hospitalization complicated by ileus and AKI requiring HD (now resolved).
He has been hospitalized 62 days.
The ICU team calls you for ?refractory delirium?
A #ContinuumCase (image mine)
2/
On exam you find a man that is frail and inattentive. He is slow with tracking you around the room.
He does not participate in serial 7s or saying the days of the week backwards.
He’ll follow simple commands and is able to name simple objects.
On exam you find a man that is frail and inattentive. He is slow with tracking you around the room.
He does not participate in serial 7s or saying the days of the week backwards.
He’ll follow simple commands and is able to name simple objects.
3/
The primary team has stopped all CNS effecting drugs. His electrolytes reflect a BUN of 42, mild transaminitis. Ammonia was already checked and is 34.
They got an MRI too look for strokes.
What do you think?
The primary team has stopped all CNS effecting drugs. His electrolytes reflect a BUN of 42, mild transaminitis. Ammonia was already checked and is 34.
They got an MRI too look for strokes.
What do you think?
4/
Yes! the above scan demonstrates abnormalities in the thalami, mammillary bodies, tectal plate and peri-aquaductal gray area – classic for Wernicke Encephalopathy from Thiamine deficiency.
Reminder: Wernicke Syndrome is a triad of confusion, opthalmoplegia/nystagmus,& ataxia
Yes! the above scan demonstrates abnormalities in the thalami, mammillary bodies, tectal plate and peri-aquaductal gray area – classic for Wernicke Encephalopathy from Thiamine deficiency.
Reminder: Wernicke Syndrome is a triad of confusion, opthalmoplegia/nystagmus,& ataxia
5/
The full syndrome is present in <20% of patients.
ICU patients are at high, and likely underrecognized, risk for thiamine deficiency.
Although alcoholism is the classic risk factor, consider in:
-GI disease
-Malabsorption
-Bariatric surgery
-Hyperemesis
-HD
-Prolonged NPO
The full syndrome is present in <20% of patients.
ICU patients are at high, and likely underrecognized, risk for thiamine deficiency.
Although alcoholism is the classic risk factor, consider in:
-GI disease
-Malabsorption
-Bariatric surgery
-Hyperemesis
-HD
-Prolonged NPO
6/
2⃣ #ContinuumPearls:
🌟Thiamine is a co-factor in the krebs cycle: pts w/ a persistent (and otherwise unexplained) lactic acidosis may be thiamine deficient!
🌟Metronidazole can cause inhibition of thiamine pyrophosphylation ➡️ triggering Wernicke's encephalopathy!
2⃣ #ContinuumPearls:
🌟Thiamine is a co-factor in the krebs cycle: pts w/ a persistent (and otherwise unexplained) lactic acidosis may be thiamine deficient!
🌟Metronidazole can cause inhibition of thiamine pyrophosphylation ➡️ triggering Wernicke's encephalopathy!
7/
The diagnosis is hard to make as B1 levels take time to return.
If you have any concern, it is best to just use high dose IV thiamine (500mg Q8H) for replacement.
While you’re at it, consider replacing B12, factor, and other fat-soluble vitamins.
The diagnosis is hard to make as B1 levels take time to return.
If you have any concern, it is best to just use high dose IV thiamine (500mg Q8H) for replacement.
While you’re at it, consider replacing B12, factor, and other fat-soluble vitamins.
7/
OH, and don’t forget magnesium replacement!!
Magnesium is a cofactor for thiamine and so it also needs to be repleted for thiamine to be effective.
OH, and don’t forget magnesium replacement!!
Magnesium is a cofactor for thiamine and so it also needs to be repleted for thiamine to be effective.
8/
For SO many other pearls, the article by @namorrismd and @aartisarwal in this issue of Continuum is truly brilliant.
I love the author interview as well!
check it out: journals.lww.com
@AANmember @ContinuumAAN @LyellJ
For SO many other pearls, the article by @namorrismd and @aartisarwal in this issue of Continuum is truly brilliant.
I love the author interview as well!
check it out: journals.lww.com
@AANmember @ContinuumAAN @LyellJ
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