Thiamine and Dextrose

[GMCmedic]

I like to think I work at a pretty progressive service. We draw cultures, administer antibiotics, ketamine, no more Lasix, we have Dual sequential defib, and not only took morphine out of the ACS protocol, but got rid of it all together.

Every time I get start to get excited about it, I remember that we still carry thiamine.

Does anyone else still use this in alcoholic hypoglycemia patients?

Sent from my SAMSUNG-SM-G920A using Tapatalk

 

[StCEMT]

I had it, but I never touched it. It was one of those I only kind of remembered what we were supposed to do with it, but I doubt I would have cared to use it.

 

[NomadicMedic]

My area has a very large population of homeless alcoholic abusers. We use it with D50 for hypoglycemia when treating individuals in that population set. I'd gather it gets used a a few times a month in our service.

 

[VentMonkey]

I'm curious as to why you think this is considered archaic, or displays lack of progression? If anything you're light years ahead of my service, county, and state (yeah, yeah, yeah California blee, bloo, blah...). In all seriousness, I would be curious to know what patient population it's written in your protocols for though.

Is it simply for any suspected long-term, and/ or malnourished alcoholic with hypoglycemia? If so, I haven't found anything saying that giving thiamine in these patients is completely wrong, outdated, or even a bad thing. I would be curious what folks such as @ERDoc are doing with these patients these days when they present to them in there ED's. FWIW, I'm referencing the Wernicke-Korsakoff Syndrome alcoholics specifically.

https://www.ebmconsult.com/articles/thiamine-administration-before-iv-glucose-alcoholics

I don't work in your system, and don't know what your medical director is like, but perhaps you can ask them as well and report back to us, Mazel.

 

[RocketMedic]

We've got thiamine here at Creek. It's fairly common to use.

 

[StCEMT]

So is alcoholic hypoglycemia the main use for it? That's the only one I ever heard, but it used to be for me to use it in coma of unknown origin. I would have so many other things I would look for first that I doubt I would mess with it by the time I got everything else I wanted done in that case.

 

[GMCmedic]

Its simply used for chronic alcoholics with hypoglycemia. Were lucky if we use it once a year.

I wouldnt call it archaic, and I would agree that its not going to hurt anything other than personally annoy me.

In all my searching I havent found a single case of Wernicke's Encephalopathy after a single dextrose bolus and literature seems to agree that Thiamine can wait for the ED.

Sent from my SAMSUNG-SM-G920A using Tapatalk

 

[Brandon O]

Jeez, just give the thiamine, people. You're not saving the world here.

 

[E tank]

Jeez, just give the thiamine, people. You're not saving the world here.

I think the question really is whether or not that should be the ED's job, not the ambulance crew. One more drug, one more outdate, one more inventory. Where does it end?

 

[Brandon O]

I think the question really is whether or not that should be the ED's job, not the ambulance crew. One more drug, one more outdate, one more inventory. Where does it end?

Fair enough. Although if we're really going to start rooting through the drug box and asking which meds have good evidence that they need to be given in the field, it may quickly turn into a drug wallet. At some point things end up as prehospital therapies merely under the philosophy of "bringing the hospital to the patient."

But no, I don't know (and rather doubt) if there's data on giving, say, a single amp of D50 prior to thiamine in at-risk patients. The study would be hard as there is not too much frank Wernicke's anymore -- although we may be missing some -- but that is partly because we go around prophylaxing people. It's not an imaginary disease and it's quite a drag to cause it unnecessarily.

Maybe it could be done, but then, the study might cost more than the drug...

 

[E tank]

... there is not too much frank Wernicke's anymore -- although we may be missing some -- but that is partly because we go around prophylaxing people. It's not an imaginary disease and it's quite a drag to cause it unnecessarily.

Right...and the Korsakoff's comes years later perhaps....the blood draw for thiamine deficiency is more expensive than the vitamin. We put in foleys for less...with far greater risk...

 

[Brandon O]

Zactly. I'm all for rationalizing and simplifying, but at some point it's like asking for an RCT before you'll give people pillows.

 

[Carlos Danger]

Fair enough. Although if we're really going to start rooting through the drug box and asking which meds have good evidence that they need to be given in the field, it may quickly turn into a drug wallet.

Exactly.

It's always interesting the way many folks are all about bringing the hospital to the patient when it comes to airway management and ultrasound and antibiotics, despite the lack of data supporting such things being done in the field, but are quick to say "it can wait till we get the ED" when to comes to the less sexy things, like thiamine and methylprednisolone and cleaning up soiled patients.

 

[CWATT]

I have Thiamine in three of my four licensed jurisdictions. A note, because of the metabolic role Thiamine plays in carbohydrate metabolism, it should be administered prior to D50W in indicated patients, otherwise the condition might worsen (as according to my protocols).

@GMCmedic, why is removing Morphine progressive? What is it you/your service does not like about the drug? What evidence contradicts its use with ACS?

 

[ERDoc]

When I started banana bags with thiamine and folate were pretty much standard. Over time they have fallen out of favor since most of these people were such regular visitors that they were being overdosed. Most of them end up getting enough in their diet from the meals they get in the ER. I honestly can't remember the last time anyone used thiamine in any of the 3 ERs I work in.

 

[Brandon O]

When I started banana bags with thiamine and folate were pretty much standard. Over time they have fallen out of favor since most of these people were such regular visitors that they were being overdosed. Most of them end up getting enough in their diet from the meals they get in the ER. I honestly can't remember the last time anyone used thiamine in any of the 3 ERs I work in.

I think there's a distinction here between the routinely-binging found-down often-homeless in-and-out of the ED frequent fliers, and the fairly stable "pint or two a day" drinkers who actually tend to stay out of the hospital.

Interestingly it usually seems to be the latter who admit as major traumas. It's been ages since we had a homeless person in the unit.

 

[GMCmedic]

@GMCmedic, why is removing Morphine progressive? What is it you/your service does not like about the drug? What evidence contradicts its use with ACS?

While nothing contradicts its use and I am well aware it is still widely used. The Studies, which names I dont readily recall dating back to 2010 and 2012 showing an increased mortality with morphine use is part of it. The other part is my Medical Director just doesn't like it.

Weve seen no change in outcomes using aggressive nitro administration with dilaudid or fentanyl for pain.

Sent from my SAMSUNG-SM-G920A using Tapatalk

 

[VentMonkey]

I sure love me some Fentanyl over MS any day of the week. It's potency, duration, and ability to typically maintain hemodynamic stability makes it perfect for what we (specifically) would use it for.

Also, they finally took all of the MS and Valium out of our narcotics kits. Back to Thiamine?