In suspected alcoholic ketoacidosis, what is the critical initial management step before giving dextrose?

• A. Immediate dextrose infusion
• B. Thiamine before dextrose
• C. Administer steroids
• D. Initiate cooling

Answer: (B)

Thiamine deficiency is common in patients with suspected alcoholic ketoacidosis due to chronic alcohol use and poor nutrition. Thiamine is a crucial cofactor for carbohydrate metabolism; when glucose is given before replenishing thiamine, the body’s demand for thiamine skyrockets and cellular energy production falters, which can precipitate or worsen Wernicke’s encephalopathy and worsen lactic acidosis.

Therefore, the critical initial step is to administer thiamine promptly, then proceed with dextrose-containing fluids to address hypoglycemia and ketosis. Steroids and cooling have no role in this scenario, and giving dextrose first without prior thiamine raises the risk of neurologic complications in this malnourished, alcohol-using patient.