Elsevier

Nutrition

Volume 25, Issue 2, February 2009, Pages 142-146
Nutrition

Brief communication
Wernicke's syndrome during parenteral feeding: Not an unusual complication

https://doi.org/10.1016/j.nut.2008.08.003Get rights and content

Abstract

Objective

Wernicke's encephalopathy (WE) is an acute disorder due to thiamine deficiency, characterized by ophthalmoplegia, ataxia, and mental confusion, similar to that classically observed in alcoholism. Some cases of WE were reported to coincide with other conditions such as hyperemesis gravidarum, bariatric surgery, and total parenteral nutrition. In this study the objective was to retrospectively evaluate the prevalence of WE among intravenously fed patients in our hospital during the previous 2 y.

Methods

Among all cases of WE diagnosed by cranial magnetic resonance scan during a 2-y period in the Azienda Ospedaliera of Padua, we identified patients who exhibited WE during parenteral feeding. Albumin plasma levels, measured at the onset of WE symptoms, were used to estimate nutritional status.

Results

We found seven cases of WE that coincided with intravenous feeding. WE occurred, on average, 13 d after the start of glucose infusion. The five subjects with albumin plasma levels lower than 35 g/L at the onset of WE received glucose infusion for fewer days. In six cases the clinical signs disappeared the day after thiamine infusion. In one case mental function did not normalize and the patient developed Korsakoff's syndrome despite prolonged thiamine treatment.

Conclusion

During a 2-y period we observed a high prevalence of WE in intravenously fed patients due to lack of thiamine supplementation. A prophylactic treatment must be performed in at-risk patients and multivitamin infusion containing thiamine must be administered daily during the course of intravenous feeding.

Introduction

Thiamine, a water-soluble B-complex vitamin, is involved in numerous bodily functions. A major biologically active form of thiamine is thiamine pyrophosphate, sometimes called thiamine diphosphate, and cocarboxylase. Thiamine pyrophosphate is a coenzyme for pyruvate dehydrogenase, α-ketoglutarate dehydrogenase, branched-chain α-keto acid dehydrogenase, and transketolase. The first two enzymes are important for carbohydrate metabolism and transketolase functions in the pentose phosphate pathway. Thiamine requirement is related to caloric and carbohydrate intake [1]. The recommended dose of thiamine for an average, healthy adult is 0.5 mg/1000 kcal consumed or 1.4 mg/d [2]. When metabolic rate is increased, as in critically ill patients or during pregnancy, the thiamine requirement increases [3]. Thiamine deficiency in humans causes cardiovascular disease, “wet beriberi,” and nervous system diseases such as peripheral neuropathy, “dry beriberi,” and Wernicke-Korsakoff syndrome. Wernicke's encephalopathy (WE) is an acute disorder characterized by ophthalmoplegia, ataxia, and mental confusion [4], classically observed in alcoholism [5]. Some cases of WE were reported in the presence of other conditions such as hyperemesis gravidarum [6], bariatric surgery [7] and total parenteral nutrition (TPN) [8].We recently reported a case of WE in a patient nourished with TPN without vitamin supplementation [9]. In this study the objective was to retrospectively evaluate the prevalence of WE among intravenously fed patients in our hospital during the previous 2 y.

Section snippets

Materials and methods

We evaluated all cranial magnetic resonance scans (CMRSs) performed between June 1, 2005 and June 30, 2007 in the Azienda Ospedaliera of Padua to identify the cases of WE present in intravenously fed subjects. The neuroradiologic WE diagnosis was made based on the presence of increased T2-weighted, fluid-attenuated inversion recovery and diffusion-weighted imaging signal symmetrically surrounding the aqueduct and the third ventricle in the mamillary bodies, on the floor of fourth ventricle, in

Results

Between June 1, 2005 and June 30, 2007 we found eight cases of WE, diagnosed by CRMSs. Seven of these occurred during parenteral feeding. During the same period 5411 subjects received TPN in our hospital.

Four subjects were men and three were women. Their mean age was 65.5 ± 16.8 y (range 46–86). All subjects were surgical inpatients. The reasons for parenteral feeding were mechanical ileus in three cases, acute pancreatitis in two cases, and cancer in two cases. None of these patients reported

Discussion

Wernicke's encephalopathy is a rare complication of thiamine deficiency among non-alcoholic subjects. Nonetheless, we observed seven cases of WE that occurred during intravenous feeding in a 2-y period. Two patients developed WE during TPN performed with industrial tricompartmental bags. Industrial tricompartmental bags have been successfully used in clinical nutrition because they can be stored longer than the pharmacy-compounded bags. Industrial tricompartmental bags contain macronutrients

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