How to manage ICU psychosis in a patient with chronic liver disease?

Management of ICU Psychosis in Patients with Chronic Liver Disease

For ICU psychosis in patients with chronic liver disease, first rule out hepatic encephalopathy (HE) and other organic causes, then use short-acting sedatives like dexmedetomidine or propofol when necessary, while avoiding benzodiazepines and minimizing opioids. 1

Initial Assessment and Differential Diagnosis

• Altered mental status in patients with chronic liver disease should not be automatically attributed to hepatic encephalopathy; it requires thorough investigation as HE is a diagnosis of exclusion 1
• Common alternative causes include alcohol intoxication/withdrawal, drug-related issues, infections, electrolyte disorders, intracranial bleeding, seizures, and primary psychiatric disorders 1
• These conditions can coexist with HE and synergize to worsen mental status 1
• Routine investigations should include:
  • Metabolic laboratory assessment 1
  • Drug, alcohol, and medication history and levels 1
  • Brain imaging in cases of first episode, seizures, focal neurological signs, or inadequate response to therapy 1

Management Algorithm

Step 1: Airway Protection and Monitoring

• Transfer patients with altered mental status to a monitored setting to prevent aspiration and falls 1
• Consider intubation for patients unable to maintain airway, with massive GI bleeding, or respiratory distress 1
• Discuss goals of care before intubation when possible 1

Step 2: Identify and Treat Underlying Causes

• Investigate for hepatic encephalopathy using West Haven criteria and Glasgow Coma Scale 1
• Identify precipitating factors of HE, which include:
  • Infections 1
  • GI bleeding 1
  • Electrolyte disorders 1
  • Acute kidney injury 1
  • Alkalosis 1
  • Dehydration 1
  • Constipation 1
  • Inappropriate lactulose use 1
  • Sedative medications 1

Step 3: Empiric Treatment for Suspected HE

• Start lactulose if HE is suspected (orally or via nasogastric tube) 1
• For Grade 3-4 HE or ileus, consider lactulose enema (300 mL lactulose in 700 mL water) 1
• Titrate to achieve 2-3 soft stools per day 2, 3
• Consider polyethylene glycol if patients are at risk of ileus/abdominal distention 1
• The role of rifaximin as add-on therapy remains under investigation but may be considered for recurrent episodes 1, 3

Step 4: Appropriate Sedation and Pain Management

• For sedation in intubated patients, use short-acting medications:
  • Propofol is preferred due to short half-life 1
  • Dexmedetomidine (alpha-2 adrenergic agonist) can reduce ventilation duration, preserve cognitive function, and reduce need for benzodiazepines in alcohol withdrawal 1
• Avoid or minimize medications with sedative effects:
  • Benzodiazepines should be avoided due to synergistic impact 1, 4
  • Minimize opioids but provide adequate pain control to prevent hyperalgesia 1
  • Use low doses with frequent readjustment and titration to mental status 1
  • Avoid gabapentin due to synergistic sedative effects 1

Special Considerations

• Routine ammonia level testing is not recommended for diagnosis of HE 1
• A low ammonia level in patients with confusion should prompt investigation for other etiologies 1
• Psychotic symptoms like visual and olfactory hallucinations may occur in HE, but auditory hallucinations are uncommon and suggest other causes 5
• Some medications can mimic or worsen encephalopathy:
  • Propranolol has been reported to cause hallucinations in cirrhotic patients 5
  • Neuroleptics, mood stabilizers, and some antidepressants can cause drug-induced liver injury 6
• For management of agitation, haloperidol is generally safer than benzodiazepines in the presence of liver disease 4

Follow-up and Prevention

• Before discharge, confirm neurological status and educate caregivers that it may change as acute illness resolves 1
• Plan outpatient consultations to adjust treatment and prevent recurrence of precipitating factors 1
• Educate patients and relatives about medication effects, importance of adherence, early signs of recurring HE, and actions to take if recurrence happens 1
• Monitor for neurological manifestations to adjust treatment and investigate signs of recurring HE 1
• Consider liver transplantation evaluation for patients with recurrent intractable HE 1, 3