From the Guidelines
In patients with hyperammonemia due to cirrhosis, normal saline (0.9% sodium chloride) is the preferred crystalloid fluid of choice. The recommended initial fluid resuscitation is 10-20 mL/kg of normal saline, followed by maintenance fluids based on the patient's clinical status and laboratory parameters 1. Lactated Ringer's solution should be avoided because it contains lactate, which can potentially worsen hyperammonemia in cirrhotic patients since impaired liver function may limit lactate metabolism.
Key Considerations
- Fluid management in these patients requires careful monitoring of electrolytes, particularly sodium levels, as hyponatremia is common in advanced cirrhosis and can worsen hepatic encephalopathy 1.
- Volume status should be assessed frequently, as both under-resuscitation and fluid overload can be detrimental.
- Patients with cirrhosis often have baseline third-spacing of fluids and may require more volume than expected, but they are also susceptible to pulmonary edema with excessive fluid administration.
- Concurrent treatment of hyperammonemia should include lactulose and rifaximin to reduce ammonia production in the gut while addressing fluid needs 1.
Additional Recommendations
- Monitoring blood sodium levels in decompensated cirrhosis is suggested because severe hyponatraemia is a predisposing factor for hepatic encephalopathy 1.
- Limiting the prescription of proton pump inhibitors to their strict validated indications and avoiding benzodiazepines in patients with decompensated cirrhosis are also recommended 1.
From the Research
Crystalloid Fluids in Hyperammonia Cirrhosis
- The provided studies do not directly address the use of crystalloid fluids in hyperammonia cirrhosis 2, 3, 4, 5, 6.
- However, the studies discuss the treatment of hepatic encephalopathy (HE) and hyperammonemia in patients with cirrhosis, which may be relevant to the management of hyperammonia cirrhosis.
- Rifaximin and lactulose are commonly used to treat HE and reduce blood ammonia levels 2, 3, 4, 5, 6.
- The studies suggest that rifaximin is effective in reducing blood ammonia levels and improving hepatic spare ability and refractory ascites in patients with cirrhosis 3.
- Additionally, rifaximin has been shown to be effective in preventing the recurrence of overt HE and reducing hospitalizations in patients with cirrhosis 4, 6.
- The use of crystalloid fluids in hyperammonia cirrhosis may be related to the management of dehydration and electrolyte imbalances, which can occur in patients with cirrhosis and HE.
- However, without direct evidence, it is unclear what role crystalloid fluids play in the management of hyperammonia cirrhosis 2, 3, 4, 5, 6.
Treatment of Hepatic Encephalopathy
- The treatment of HE typically involves the use of nonabsorbable disaccharides, antibiotics, and probiotics to reduce gut ammoniagenesis and systemic inflammation 5.
- Rifaximin and lactulose are commonly used to treat HE and reduce blood ammonia levels 2, 3, 4, 5, 6.
- Nutritional support and correction of hypokalemia, hypovolemia, and acidosis are also important in the management of HE 5.
- Early and aggressive treatment of infection, avoidance of sedatives, and modification of portosystemic shunts are also helpful in reducing the neurocognitive effects of hyperammonemia 5.
Rifaximin in Preventing Hepatic Encephalopathy
- Rifaximin has been shown to be effective in preventing HE in patients with cirrhosis, with a beneficial effect on the primary prevention of HE 6.
- Rifaximin has also been shown to decrease the recurrence risk of HE in secondary prevention 6.
- The use of rifaximin is associated with a lower risk of diarrhea compared to nonabsorbable disaccharides (NADs) 6.