Thiamine - An essential component in the management of DKA/HONK

A 65year old male with history of poorly controlled type 2 DM since 20years on OHA and borderline systemic hypertension on hydrochlorothiazide presented to the casualty with vomiting and tiredness. On evaluation he was found to have very high blood sugars. Urine ketone bodies were strongly positive. He was initiated on DKA regimen with insulin infusion and IV saline with hourly blood sugar monitoring and 4th hourly serum electrolyte measurements mainly K+. The next day patient was found to be drowsy in spite of normalized blood sugar levels, corrected acidosis and dyselectrolaemia. Chest auscultation showed bilateral crepitations. Fluid overload, LV dysfunction and cerebral edema were thought of. CT brain did not reveal cerebral edema. ECG was unremarkable except for sinus tachycardia. ECHO showed low ejection fraction (25%) with a dilated heart. Cardiac enzymes and ECGs were normal in spite of serial monitoring. RFTs were within normal range.2 days passed and patient was remaining drowsy, disoriented and in pulmonary venous congestion in spite of controlled infusion of IV fluids with CVP monitoring. Considering a background history chronic alcohol abuse, poor general nutrition, on and off use of frusemide for dependent pedal edema possibility of thiamine deficiency was thought of and  he was started on IV thiamine. Within a day or 2 patient had a remarkable restoration of sensorium, and follow up ECHO showed an improvement of EF to 65%. Quantitative essay of thiamine report came after five days which was low. Patient had severe encephalopathy and cardiovascular manifestations of thiamine deficiency precipitated by high carbohydrate metabolic turn over seen in DKA with a background history of alcoholism and poor nutrition both well known to cause thiamine deficiency. He was also using diuretics which will deplete an already limited  thiamine stores. From the above case one will see that it is always prudent to add thiamine to the management protocol for DKA/HONK. Thiamine estimation is unavailable many a times and time consuming also.