What interventions are recommended for a patient with hepatic encephalopathy, tachycardia, and hyperlactatemia, who is currently asymptomatic, and has a history of cirrhosis and hypotension, for which Nephrology (Nephro) wants to withhold Intravenous Fluids (IVF)?

From the Guidelines

I recommend initiating lactulose therapy to prevent recurrence of hepatic encephalopathy in this patient with cirrhosis, as it is a non-absorbable disaccharide that has been shown to be effective in preventing recurrence of HE 1. Given the patient's current asymptomatic status with heart rates in the 100-120s range and a mildly elevated lactate of 2.4, aggressive interventions for the tachycardia or lactic acidosis may cause more harm than benefit. The primary focus of treatment should be on addressing the underlying hepatic encephalopathy, identifying and managing any precipitating factors such as infection, GI bleeding, electrolyte abnormalities, or medication effects, as recommended by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases 1. Some key points to consider in the management of this patient include:

• Monitoring trends in vital signs and assessing for signs of dehydration
• Considering small fluid challenges (250cc) if the patient develops symptoms or worsening tachycardia, while being mindful of nephrology's concern about volume overload in cirrhosis
• Regular reassessment of mental status, vital signs, and laboratory values including electrolytes, BUN/creatinine, and repeat lactate in 4-6 hours to guide further management decisions
• The use of rifaximin in addition to lactulose may be considered for prevention of recurrence of HE, as suggested by the French recommendations 1 and other guidelines 1. It is also important to note that liver transplantation may be indicated in patients with severe HE who do not respond to medical treatments, as recommended by the Korean Association for the Study of the Liver 1. Overall, the management of this patient should prioritize the prevention of recurrence of hepatic encephalopathy, careful monitoring of vital signs and laboratory values, and addressing any precipitating factors that may be contributing to the patient's condition.

From the FDA Drug Label

The usual adult, oral dosage is 2 to 3 tablespoonfuls (30 mL to 45 mL, containing 20 grams to 30 grams of lactulose) three or four times daily. Hourly doses of 30 mL to 45 mL of lactulose solution may be used to induce the rapid laxation indicated in the initial phase of the therapy of portal-systemic encephalopathy.

The patient has hepatic encephalopathy and is asymptomatic at this time. Lactulose is commonly used to treat hepatic encephalopathy.

• The patient's lactic acid level is 2.4, which is not directly relevant to the treatment of hepatic encephalopathy with lactulose.
• The patient's heart rate is in the 100s to 120s, which is not a contraindication for lactulose.
• Nephrology is concerned about holding off on IVF due to the patient's cirrhotic state and soft blood pressure, but this does not directly impact the decision to use lactulose for hepatic encephalopathy. Given the patient's condition, lactulose may be considered as a treatment option, but the decision to start treatment should be made with caution and careful consideration of the patient's overall clinical status 2.

From the Research

Patient Assessment

• The patient is asymptomatic with a heart rate in the 100s to 120s and a lactic acid level of 2.4.
• The nephrologist wants to hold off on IV fluids due to the patient's cirrhotic state and soft blood pressure.

Treatment Considerations

• According to 3, lactulose is effective for the prevention of overt hepatic encephalopathy recurrence over the long term, and the addition of rifaximin to lactulose significantly reduces the risk of overt hepatic encephalopathy recurrence and hepatic encephalopathy-related hospitalization.
• However, the patient's current condition and lactic acid level do not directly relate to the use of lactulose or rifaximin, as these medications are primarily used to treat hepatic encephalopathy.
• Regarding the use of IV fluids, 4 suggests that the optimal choice of infusate should be guided by the cause of hypovolemia, the cardiovascular state of the patient, the renal function, as well as the serum osmolality and the coexisting acid-base and electrolyte disorders.
• The patient's lactic acid level of 2.4 may indicate a mild lactic acidosis, but according to 5, the treatment of lactic acidosis should focus on eliminating the triggering conditions, and sodium bicarbonate administration does not improve cardiovascular function or reduce mortality.
• Additionally, 6 and 7 provide information on respiratory alkalosis and lactic acidosis, respectively, but do not directly relate to the patient's current treatment considerations.