Hepatic Coma Treatment
History and Diagnosis
History of liver disease +
Signs of liver cell failure
Jaundice
Hemetemesis or Malena
Altered consciousness or coma
Flaps
Hepatic coma causes and precipitating factors
Liver cell failure
High ammonia
Bleeding in GIT
High protein load in GIT
Potassium deficiency by high diuretics
alkalosis
constipation
opioid, sedative use
systemic/ hepatic infections
Clinical Evaluation (Hepatic Coma Treatment)
• Respiratory function
• Need for oxygen and ventilatory support.
• Blood pressure monitoring
• Ryles tube aspiration for detection of upper gastrointestinal bleeding.
• Detect infections if any
• Detect bleeding tendency.
Investigations
1. CBC
2.Blood glucose
3. Serum electrolytes
4.Blood urea and creatinine
5. Liver function tests
6. Serum ammonia (elevated) (normal 12-55 micro mol/L)
7. Prothrombin time, bleeding time (usually elevated) and platelet count
8. Chest X-ray
9. E.C.G.
10. Arterial Blood Gases if necessary.
hepatic coma ammonia levels
Serum ammonia (elevated) means more than 55 micro mol/L, (normal 12-55 micro mol/L)
hepatic coma symptoms, Clinical stages of Hepatic Encephalopathy (HE)
| Stage | Mental state | Flap | EEG |
| i | personality changes, Euphoria, Depression, Mild confusion, Slurred speech, and altered sleep rhythm | +/- | Normal |
| ii | Lethargy and Moderate confusion, behavioral changes | + | Abnormal |
| iii | Marked confusion, Incoherent speech, amnesia | + | Abnormal |
| iv | Stupor, Coma | – | Abnormal |
Hepatic Coma Treatment
1. Ensure respiratory function
2. Maintain the blood pressure with IV fluid/ Plasma/ Blood.
3. Pass a Ryles tube for aspiration of stomach content
A. If the aspirate show brownish/ blood stained content
a) Wash the stomach with cold saline,
b) Instil antacid or Sucralfate 15 ml Q6H or I/V Omeprazole 20 mg Q12H,
c) No oral or Rylés tube feeding,
d) Continuous gravity assisted Ryles tube drainage
B. If the aspirate is clear
(a) Consider feeding through the Ryles tube
(b) Cap. Omeprazole 20mg Q12H can be given.
4. Lactulose 15-30ml Q6H till 3 -4 loose stools per day is passed.
5. Rafaximin 550mg BD reduces hospitalization or Tab. Metronidazole 400 mg Q8H also effective
6. Ornithine aspartate orally 9gm TID, If renal function good, No sedatives.
Consider Oxazepam 10-30 mg (not metabolised by liver) Only if needed very badly in a unmanageable patient.
7. Careful use of diuretics.
8. 60-80g/day proteins.
9. Bowel washes at least two times a day.
10. Systemic Antibiotics (Broad-spectrum antibiotics) for systemic infections.
11. Fluids and Calories
a) 35 Kcal/Kg/day is required. Start IV 10% Dextrose drip with additional 50% Dextrose sos. b) Avoid hypokalemia. c) Vitamin B1 100mg IV is given daily in alcoholic
12. Other supportive measures
a) If generalised bleeding tendency is present, consider fresh blood or fresh frozen plasma transfusion.
b) Inj. Vitamin K 10mg SC/IV OD for 3 days if prothrombin time is prolonged, may not be effective.
c) Avoid unnecessary arterial punctures, if high PT/INR.
d) No mechanical suction during gastric aspiration.
e) Treatment for cerebral edema with inj. Mannitol 50ml IV Q8H, if renal function is normal.
f) Use of steroids is controversial and better avoided except in cases of autoimmune hepatitis.
13. Management of oliguria and renal failure plasma volume expansion/ hemodialysis, If Hepatorenal syndrome Terlipressin 1mg Q6H, Human Albumin 100ml.
14. Monitor the following parameters frequently
a) Blood pressure
b) Blood sugar as Hypoglycaemia is common.
e) Blood urea and creatinine.
f) Serum alectrolytes.
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