BUMC Basics.pdf - Anesthesia Home

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Stage 1: Mild confusion, decreased attention,
irritability, reversed sleep pattern
Stage 2: Drowsiness, personality changes,
intermittent disorientation, asterixis
Stage 3: Gross disorientation, marked confusion,
slurred speech
Stage 4: Frank coma
The grading/staging of HE can be difficult. The presence of
asterixis is a fairly reliable indicator of at least stage II HE.
** Always look for what precipitated the HE. Common
etiologies: Infection, bleeding, electrolyte abnormality,
dehydration.
• Kristalose (same as Lactulose but tastes better and
comes as packets of crystals): a good starting does is 20-
30 g po TID, then titrate to 3-4 BM/day
• Rifaxamin: 400 mg PO TID- this is very expensive, and
so it can be difficult to continue as an outpatient
• For your patients with Stage III/IV HE or refractory HE:
Kristalose 30-60 grams every hour until BM. Lactulose
enema: 200 g of lactulose in 800-1000 mL water
Ascites-volume overload
Large volume paracentesis is greater than >2L
If the patient’s serum albumin is less than 3 g/dL, then give 8 to
10 g of albumin per liter of ascites removed. All albumin at
Baylor is “sodium poor” so no need to specify “sodium poor
albumin- SPA”. Albumin comes in 25 g vials, so it is best to
round to the next highest 25 g interval. Usually best to hang
the albumin as you are about to do the tap.
• Diagnostic paracentesis - SBP, etc.
- Send for: cell count/diff, albumin, total protein
- Inoculate culture bottles at bedside with 10 mL of
ascitic fluid in each bottle (increases yield)
- SBP if >250 PMNs
• Coagulopathy is not a contraindication to paracentesis.
In general, we do not give FFP or platelets prior to a
paracentesis unless the patient has a severe
coagulopathy