What are the initial treatment orders for a patient admitted with hepatic encephalopathy?

Initial Treatment Orders for Hepatic Encephalopathy

The first-line treatment for patients admitted with hepatic encephalopathy is lactulose with an initial dosing of 30-45 mL every 1-2 hours until 2 bowel movements occur, followed by maintenance dosing of 25-30 mL orally every 12 hours, targeting 2-3 soft stools per day. 1

Step 1: Identify and Address Precipitating Factors

• Search for and treat common precipitating factors:
  • Gastrointestinal bleeding
  • Infection/sepsis
  • Electrolyte abnormalities
  • Dehydration
  • Constipation
  • Medication non-compliance
  • Excessive protein intake
  • Renal dysfunction

Step 2: Initial Medication Orders

1. Lactulose:

   • Initial dose: 30-45 mL every 1-2 hours until 2 bowel movements occur 1
   • Maintenance: 25-30 mL orally every 12 hours, titrated to achieve 2-3 soft bowel movements daily 2, 1
   • For patients unable to take oral medications: Lactulose enemas (300 mL in 700 mL water) 3

2. Rifaximin:

   • Add 550 mg orally twice daily if:
     • Patient has had previous episodes of HE
     • Not responding adequately to lactulose alone 2, 1
   • Particularly important for secondary prophylaxis following multiple episodes of overt HE 2

Step 3: Airway Management and Level of Care

• For patients with Grade III-IV HE (severe confusion, stupor, or coma):
  • Admit to ICU for close monitoring
  • Secure airway if Glasgow Coma Scale <7
  • Position head elevated at 30 degrees to reduce aspiration risk 1

Step 4: Nutritional Support

• Provide adequate nutrition:
  • Daily energy intake: 35-40 kcal/kg
  • Protein intake: 1.2-1.5 g/kg (do not restrict protein)
  • Schedule small, frequent meals (4-6 times/day including night snack) 1
  • Consider vegetable and dairy protein sources for patients with recurrent/persistent HE 2

Step 5: Additional Therapeutic Considerations

• For rapidly deteriorating neurological status with ammonia levels >150 μmol/L:

  • Consider continuous kidney replacement therapy (CKRT) 1

• For gastrointestinal bleeding:

  • Rapid removal of blood from GI tract using lactulose or mannitol via nasogastric tube 2

• Alternative therapies if standard therapy fails:

  • IV L-ornithine L-aspartate (LOLA): 30 g/day 1
  • Oral branched-chain amino acids (BCAAs) 1
  • Neomycin (4-12 grams per day in divided doses) - limited use due to ototoxicity and nephrotoxicity 1, 4

Step 6: Monitoring and Follow-up

• Frequent neurological evaluations to monitor mental status
• Monitor for adequate bowel movements (2-3 per day)
• Assess ammonia levels, though clinical response is more important than laboratory values
• Monitor for medication side effects

Important Caveats and Pitfalls

1. Do not restrict protein intake - this outdated practice can worsen nutritional status and outcomes

2. Routine zinc supplementation is not recommended unless deficiency is demonstrated 2

3. Neomycin should be used with caution due to risks of nephrotoxicity and ototoxicity, especially with prolonged use 1, 4

4. For patients with gastrointestinal bleeding, rapid removal of blood from the GI tract is essential to prevent worsening HE 2

5. Consider liver transplantation for patients with end-stage liver disease and recurrent or persistent HE not responding to other treatments 2