Hepatic Encephalopathy



  1. Stop sedative agents
  2. Decrease protein intake
  3. Look for and treat bleeding, sepsis
  4. Correct hypokalemia, hypoglycemia, hypoxemia, hypovolemia
  5. Treat constipation
  6. Lactulose
  7. Eradication of H. pylori may decrease ammonia level
  8. Misc Tx: 


Admit Orders: Hepatic Encephalopathy

1. Admit to:

2. Diagnosis: Hepatic encephalopathy

3. Condition:

4. Vital Signs: q1-4h. Call physician if BP >160/90, <90/60; P >120, <50; R>25, <10; T >38.5°C.

5. Allergies: Avoid sedatives, NSAIDS, or hepatotoxic drugs.

6. Activity: Bed rest.

7. Nursing: Keep head-of-bed at 30 degrees; turn patient q2h, chart stools. Seizure precautions, egg crate mattress. Foley to closed drainage.

8. Diet: NPO for 8 hours, then low-protein nasogastric enteral feedings (Hepatic-Aid II) at 30 mL/hr. Increase rate by 25-50 mL/hr at 24 hr intervals as tolerated until final rate of 50-100 mL/hr as tolerated.

9. IV Fluids: D5W at TKO.

10.Special Medications:

- Sorbitol 70% solution, 30-60 gm PO now.

-Lactulose 30-45 mL PO q1h for 3 doses, then 15-45 mL PO bid-qid, titrate to produce 3 soft stools/d OR

-Lactulose enema 300 mL added to 700 mL of tap water; instill 200-250 mL per rectal tube bid-qid AND

-Neomycin 1 gm PO q6h (4-12 g/d) OR

-Metronidazole (Flagyl) 250 mg PO q6h.

-Ranitidine (Zantac) 50 mg IV q8h or 150 mg PO bid OR

-Famotidine (Pepcid) 20 mg IV/PO q12h.

-Flumazenil (Romazicon) 0.2 mg (2 mL) IV over 30 seconds q1min until a total dose of 3 mg; if a partial response occurs, continue 0.5 mg doses until a total of 5 mg. Flumazenil may help reverse hepatic encephalopathy, irrespective of benzodiazepine use.

-Multivitamin PO qAM or 1 ampule IV qAM.

-Folic acid 1 mg PO/IV qd.

-Thiamine 100 mg PO/IV qd.

11. Extras: CXR, ECG; GI and dietetics consults.

12. Labs: Ammonia, CBC, CMP, AST, ALT, GGT, INR/PTT, ABG, blood C&S x 2. UA.