Severe lactic acidosis reversed by thiamine within 24 hours
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KeywordsThiamine Lactic Acidosis Glasgow Coma Scale Score Ophthalmoplegia Thiamine Deficiency
Thiamine is a water-soluble vitamin that plays a pivotal role in carbohydrate metabolism. In acute deficiency, pyruvate accumulates and is metabolized to lactate, and chronic deficiency may cause polyneuropathy and Wernicke encephalopathy. Classic symptoms include mental status change, ophthalmoplegia, and ataxia but are present in only a few patients . Critically ill patients are prone to thiamine deficiency because of preexistent malnutrition, increased consumption in high-carbohydrate nutrition, and accelerated clearance in renal replacement. In retrospective  and prospective [3, 4] studies, a substantial prevalence of thiamine deficiency has been described in both adult (10% to 20%) and pediatric (28%) patients. Thiamine deficiency may become clinically evident in any type of malnutrition that outlasts thiamine body stores (2 to 3 weeks), including alcoholism, bariatric surgery, or hyperemesis gravidarum, and results in high morbidity and mortality if untreated .
Thiamine deficiency may cause unspecific neurologic symptoms. Glucose administration or feeding may aggravate depletion. Thiamine deficiency is an underdiagnosed cause of lactic acidosis, although treatment is safe, inexpensive, and readily available. Current guidelines on parenteral nutrition recommend a daily intravenous dose of 100 to 300 mg of thiamine during the first 3 days in the intensive care unit when deficiency is a possibility (grade B) . In conclusion, although its clinical significance has been known for decades, thiamine deficiency remains an under-recognized condition. Intensivists should have an increased awareness of this problem and a low threshold to infuse high-dose thiamine. Future prospective studies to define the optimal dose and duration of treatment are warranted.
We thank Steven Amrein for critical review of the manuscript.