What are the initial treatment orders for a 62-year-old patient with cirrhosis presenting with confusion?

Initial Treatment Orders for Cirrhotic Patient with Confusion

For a 62-year-old patient with cirrhosis presenting with confusion, immediate empirical therapy for hepatic encephalopathy (HE) should be initiated along with investigation of precipitating factors.

Initial Assessment and Diagnostic Orders

• Order diagnostic paracentesis to rule out spontaneous bacterial peritonitis (SBP), which is essential in all cirrhotic patients with ascites presenting with altered mental status 1
• Check complete metabolic panel, complete blood count, ammonia level (though not routinely recommended, a low level would point to etiologies other than HE) 1
• Order drug and alcohol levels to rule out intoxication or withdrawal 1
• Consider brain imaging (CT or MRI) if this is the first episode of confusion, if there are focal neurological signs, or if the patient doesn't respond to empiric therapy 1
• Investigate common precipitating factors including:
  • Infections (blood cultures, urinalysis, chest X-ray)
  • GI bleeding (stool guaiac test, CBC for anemia)
  • Electrolyte disorders (particularly sodium, potassium)
  • Acute kidney injury (BUN, creatinine)
  • Medication review for sedatives or other central nervous system depressants 1

Immediate Treatment Orders

• Start lactulose 20-30g (30-45mL) orally every 1-2 hours until at least 2 soft bowel movements are produced, then adjust to 3-4 times daily 2, 3
• For patients unable to take oral medications, insert a nasogastric tube for lactulose administration 2, 4
• For severe hepatic encephalopathy (West-Haven grade 3 or 4), administer lactulose enema (300mL lactulose in 700mL water) 3-4 times daily 1, 2
• Consider polyethylene glycol (PEG) solution as an alternative or addition to lactulose, especially if the patient has ileus or abdominal distention, as it may lead to more rapid resolution of HE 1, 5, 6
• Add rifaximin 400mg three times daily or 550mg twice daily as adjunctive therapy to lactulose 2, 7
• Consider ICU admission for patients with Grade 3 or 4 HE for airway protection 1, 4

Supportive Care Orders

• Intravenous fluids with careful monitoring of electrolytes; consider albumin 1.5g/kg/day if evidence of hypovolemia 2
• Avoid sedatives and pain medications with long half-lives; if sedation is required, use medications with short half-lives such as propofol or dexmedetomidine 1
• Implement salt restriction (5-6.5g daily) if ascites is present 1
• Monitor for response to therapy with serial assessments using West Haven criteria or Glasgow Coma Scale 1

Management of Specific Precipitating Factors

• If SBP is diagnosed (ascitic neutrophil count >250/mm³), start immediate empirical antibiotics (cefotaxime is commonly used, but choice should be guided by local resistance patterns) 1
• For GI bleeding, initiate prophylactic antibiotics and appropriate management 1
• If dehydration is present, consider reducing or stopping diuretics temporarily 1
• For hyponatremia during diuretic therapy, discontinue diuretics and expand plasma volume with normal saline 1

Monitoring Orders

• Serial mental status examinations using standardized scales (West Haven criteria, Glasgow Coma Scale) 1
• Daily electrolytes, renal function, and liver function tests 1
• Monitor for adverse effects of lactulose therapy including dehydration, hypernatremia, and excessive bowel movements 3
• Consider a second diagnostic paracentesis at 48 hours if SBP is diagnosed to check efficacy of antibiotic therapy 1

Common Pitfalls to Avoid

• Do not routinely measure prothrombin time and platelet count before paracentesis 1
• Avoid excessive use of lactulose as it can lead to dehydration, hypernatremia, and perianal skin irritation 3
• Do not use neomycin or metronidazole as first-line agents due to significant side effects including nephrotoxicity, ototoxicity, and peripheral neuropathy 2
• Routine ammonia level testing is not recommended for diagnosis of HE 1