Page 189 - Critical Care Notes

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Diagnostic Tests
■ CT scan or ultrasound
■ Serum chemistries, bilirubin, total protein, and albumin
■ AST, APT, ALT, and cholesterol
■ Ammonia levels
■ CBC and platelets
■ ABGs or pulse oximetry
■ ECG to detect arrhythmias
■ PT, PTT, INR, plasmin, plasminogen, fibrin, and fibrin-split products
■ Urinalysis, urine bilirubin, and urine urobilinogen
■ EEG to assess brain function if indicated
Management
■ Administer lactulose (Cephulac) orally or rectally to ↓ ammonia levels.
■ Administer neomycin orally or rectally if not contraindicated.
■ Administer diuretics such as furosemide (Lasix) if ascites present. Monitor
intake and output.
■ Prepare patient for paracentesis.
■ Measure abdominal girth; weigh daily. Assess intake and output.
■ Monitor for cardiac dysrhythmias.
■ Provide stress ulcer prophylaxis. Elevate head of bed 20°–30°. Assess for
signs of GI bleeding. Gastric suction as necessary.
■ Administer vitamin K and platelets. Use bleeding precautions. Avoid
frequent venipunctures.
■ Administer thiamine, riboflavin, pyridoxine, folic acid.
■ Treat fever and control BP.
■ Correct fluid and electrolyte imbalances. Prevent and correct hypokalemia,
which increases renal ammonia production → ammonia across the blood-
brain barrier. Avoid lactated Ringer’s solution.
■ Prevent infection. Administer prophylactic antibiotics. Consider rifaximin
(Xifaxan) or metronidazole (Flagyl).
■ Assess neurological status including mental status, level of consciousness,
Glasgow Coma Scale score, and response to verbal and noxious stimuli.
■ Assess for signs of ICP. Administer mannitol if indicated.
■ Consider sorbitol-induced catharsis to prevent osmotic diarrhea.
■ Assess respiratory status, and monitor ABGs or pulse oximetry. Correct
hypercapnia and hypoxemia via O 2 administration or mechanical ventilation.
■ Provide CRRT if renal failure present.
■ Avoid benzodiazepines and other sedatives that may mask symptoms.
Consider oxazepam (Serax), diazepam (Valium), or lorazepam (Ativan) if
sedation is required.
GI