How should this patient be managed?
- Agitation in patients with fulminant liver failure is often associated with cerebral oedema. An ammonia > 150 μmol/L indicates a high risk of cerebral oedema and ammonia > 200 μmol/L indicates a high risk of cerebral herniation
- The use of benzodiazepines and anti-psychotics (i.e. haloperidol) to control agitation is not advocated in this case. There use may worsen an intracranial hypertension leading to morbidity or mortality.
- Therefore this patient (agitated and ammonia 170 μmol/L) should immediately be intubated and undergo neuroprotective ventilation. PaC02 4.5 -5kPa, PaO2 10-12kPa, ETT taped, MAP > 70 mmHg or > 80 mmHg if concerns around intracranial hypertension (which seems likely in this case)