Wernicke encephalopathy is under-diagnosed because the classic triad of confusion, ataxia and eye-movement abnormality is present in a minority. It occurs in heavy alcohol use, but also in hyperemesis, after bariatric surgery, with prolonged vomiting and in severe malnutrition.
Parenteral thiamine is cheap and safe, so the threshold to give it should be low. Give it to at-risk patients before or with glucose-containing fluids, and use higher parenteral doses when Wernicke encephalopathy is suspected rather than the oral maintenance dose.
- Give parenteral thiamine to any patient with alcohol withdrawal or malnutrition on admission.
- Do not wait for the full triad; confusion alone in an at-risk patient is enough to treat.
- Give thiamine before or with glucose-containing fluids in at-risk patients.
- Consider Wernicke encephalopathy after bariatric surgery or prolonged vomiting, not only in alcohol use.
Why it matters
A missed Wernicke encephalopathy can become permanent memory loss, and the treatment costs almost nothing.
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