How to manage a patient with hepatic encephalopathy who is violent?

Management of Violent Patients with Hepatic Encephalopathy

For violent patients with hepatic encephalopathy, immediate management should include securing the airway, administering lactulose therapy, identifying and treating precipitating factors, and considering intensive care monitoring for those with higher grades of HE who cannot protect their airway. 1, 2

Initial Management

• Patients with higher grades of HE who are violent and unable to protect their airway need more intensive monitoring and should be managed in an intensive care setting 1
• Consider tracheal intubation for patients with deep encephalopathy to protect the airway 3
• Position patients with head elevated at 30 degrees to reduce intracranial pressure 4
• Avoid sedatives when possible as they interfere with neurological assessment and have delayed clearance in liver failure 4, 3
• If benzodiazepines are absolutely necessary for uncontrolled agitation or seizures, use only minimal doses due to their delayed clearance by the failing liver 4
• Phenytoin is recommended if seizures are present in the violent patient with hepatic encephalopathy 4

Specific Pharmacological Management

• Administer lactulose via nasogastric tube if the patient is unable to take medications orally or has an aspiration risk 1, 5
• Initial dosing of lactulose should be 25-30 mL every 1-2 hours until stool evacuation occurs, then adjust to achieve 2-3 soft stools daily 5
• For severe cases, lactulose enema can be administered: mix 300 mL of lactulose solution with 700 mL of water or physiologic saline and retain for 30-60 minutes 1, 5
• Lactulose enema may be repeated every 4-6 hours if evacuated too promptly 5
• Add rifaximin 400 mg three times daily or 550 mg twice daily if the patient's condition does not improve with lactulose alone 1, 2, 6

Identify and Treat Precipitating Factors

• Controlling precipitating factors is paramount, as nearly 90% of patients can be treated with just correction of the precipitating factor 1
• Common precipitating factors include:
  • Infections (particularly spontaneous bacterial peritonitis) 1, 2
  • Gastrointestinal bleeding 1, 2
  • Electrolyte disturbances 2
  • Medication non-compliance 2
  • Constipation 1

Additional Therapeutic Options

• Consider IV L-Ornithine L-Aspartate (LOLA) 30 g/day for patients not responding to conventional therapy 1, 2
• Oral Branched-Chain Amino Acids (BCAAs) at 0.25 g/kg/day can be used as an alternative or additional agent for patients not responding to conventional therapy 1, 2
• Brain CT imaging should be performed to exclude other causes of decreased mental status and violent behavior 4

Monitoring and Follow-up

• Monitor for improvement in mental status, which may occur within 24-48 hours but could take longer 5
• Once the patient's condition improves and they can take oral medications, transition from enema to oral lactulose 5
• Continue lactulose therapy long-term to prevent recurrence of hepatic encephalopathy 5
• Educate patients and relatives about medication effects, importance of adherence, early signs of recurring HE, and actions to take if recurrence occurs 1

Pitfalls to Avoid

• Delaying treatment while awaiting diagnostic confirmation can worsen outcomes 2
• Overuse of lactulose can paradoxically precipitate HE and cause other complications 2
• Failure to identify precipitating factors may lead to poor treatment response 2
• Long-term use of antibiotics like neomycin and metronidazole should be avoided due to risks of ototoxicity, nephrotoxicity, and neurotoxicity 1, 2