How To Administer Lactulose
If this medication is to be taken orally then it should be used three to four times daily or as instructed by a doctor. The taste can be improved by mixing it with water, fruit juice, soft dessert, or milk. The main goal here is that the patient has two to three daily soft stools. However, the dosage to be taken will depend on how responsive the patient has been and their medical condition.
When taken rectally, the recommended dosage should be mixed in normal saline or water. Apply the solution and allow the liquid to stay in the rectum for the next thirty to sixty minutes or as instructed by the doctor. If the medication is kept below thirty minutes then it should be repeated unless told otherwise.
This medication should be used regularly for optimum benefit and effect. Remember that is is to be used at the same time daily. Rectal administration of lactulose can improve mental status for like two hours. But oral administration may require up to twenty-four to forty-eight hours.
Signs And Symptoms Of Hepatic Encephalopathy
Hepatic encephalopathy symptoms vary from person-to-person and depend on the underlying cause of hepatic damage.
Hepatic Encephalopathy Nursing Care Plan 5
Nursing Diagnosis: Risk for Injury related to cognition changes, hypoxia, toxin accumulation, and physical impediments secondary to hepatic encephalopathy.
- The patient will identify causes that may potentially increase the risk of injury and demonstrate behaviors that avoid injury within 8 hours of nursing diagnosis and treatment.
- The patient will demonstrate absence of injuries within 4 hours of nursing diagnosis and treatment.
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Is Lactulose An Effective Therapy
Using lactulose for hepatic encephalopathy is a very effective therapy. But remember that it does not in any way cure H.E. It only helps to manage the symptoms, especially when it comes to your mental status. However, ensure to follow all of your doctors directions and carry him or her along with how you feel as you use the medication.
Neuropsychological Test In Mhe
Neuropsychological testing is useful methodology for quantifying cognitive impairment due to various forms of encephalopathy, including low-grade or MHE. Neuropsychological tests directly measure cognitive functions that are directly relevant to activities of daily living. They have been applied for the diagnosis of HE for more than 50 years.
The neuropsychological features of MHE point to a disorder of executive functioning, particularly selective attention, visuospatial abilities and fine motor skills. Although these domains are most commonly implicated in MHE, impairments of memory have also been reported.
The attention impairments in MHE are observed on a variety of measures. These include measures of cognitive processing speed involving psychomotor responding, such as the Number Connection tests , block design test ,the Digit Symbol test , line drawing test, circle-dotting test, serial-dotting test, figure connection test. Impairments on measures of cognitive processing speed and response inhibition that do not require a motor response have also been reported . Visuospatial impairments have been primarily reported on block design tasks , but also on more pure measures of visuospatial perception, such as line orientation or the Hooper test. Fine motor skill impairments have been noted on measures such as the grooved pegboard task, and on line tracing tasks .
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Enhancing Healthcare Team Outcomes
In the context of hepatic encephalopathy management, there are multiple decision-making steps involved to ensure the best form of patient care. These would range from the mode of administration of lactulose , the monitoring of the number of bowel movements to achieve the required frequency of 2-3 stools per day.
Communication between the physicians, pharmacists, and the nursing staff is of paramount importance to monitor frequent changes in mental status and accurately measure stool output. In certain situations, dose titration of the lactulose may also be required to prevent dehydration, diarrhea, and excoriation of the anal skin, requiring pharmaceutical intervention. Patients in the ICU who would require lactulose administered via an NG tube would need physical positioning designed to decrease the odds of aspiration.
Minimal Or Subclinical Encephalopathy
Patients with minimal hepatic encephalopathy have a normal neurological examination however they may still be symptomatic. Symptoms relate to disturbances in sleep, memory, attention, concentration and other areas of cognition. A classic sign of HE is a sleep disturbance. On a sleep questionnaire, disturbance is seen in 47% of cirrhotics compared with 4.5% of controls. A higher frequency of sleep disturbance in cirrhotic patients with MHE has been confirmed in studies using health-related quality of life questionnaires. Sleep disturbance in cirrhosis is not associated with cognitive impairment thus it may not truly be an MHE symptom. Unsatisfactory sleep is associated with higher scores for depression and anxiety, raising the possibility that the effects of chronic disease may underlie the pathogenesis of sleep disturbance. Disturbances in cirrhotics may also be related to abnormalities of circadian rhythm.
Defective memory may be a sign of MHE. Patients with MHE have impaired short- and long-term memory. This impairment is predominantly related to deficits in attention and visual perception. Memory deficit of MHE seems to comprise short-term but not long-term memory impairment. This can be described as an encoding defect, in which memory recall is intact.
Several cognitive statements and/or complaints, have predictive value for MHE, including impaired psychomotor performance impaired sleep or rest decreased attention and poor memory .
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What Dose Of Lactulose Should I Take For He
Lactulose dosage can vary, so ask your doctor about the best dose for you2. It is important not to overdose on lactulose, as you could end up experiencing severe diarrhea, which can lead to a dangerous loss of fluids and electrolytes. Overdose can also slow down the movement of your intestines the opposite effect of what you want in HE, so make sure you follow the advice of your healthcare team.1
Lactulose is a type of sugar that is commonly used as a treatment for constipation as well as for HE.
Hepatic Encephalopathy Nursing Care Plan 4
Nursing Diagnosis: Risk for Deficient Fluid Volume related to third-space shift, excessive fluid losses through vomiting and diarrhea, and alteration in the clotting process secondary to hepatic encephalopathy.
- The patient will maintain adequate hydration, as evidenced by good skin turgor, stable vital signs, normal capillary refill time, strong peripheral pulses, and urinary output within the patientâs normal range.
- The patient will demonstrate absence of signs of hemorrhage with clotting times within the normal limits.
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Risk Factors To Hepatic Encephalopathy
About half of the patients with liver cirrhosis eventually develop hepatic encephalopathy. In liver cirrhosis, there is buildup of scar tissue which blocks blood flow and impairs the liverâs ability to filter hormones, toxins, and nutrients. The following are risk factors for the development of hepatic encephalopathy:
- Hyponatremia. In individuals with cirrhosis, hyponatremia is an independent risk factor for the development of hepatic encephalopathy.
- Renal failure in cirrhotic patients. Independent of the severity of cirrhosis, cirrhotic patients with renal impairment have also been demonstrated to have an elevated risk of developing hepatic encephalopathy.
- Other risk factorsof hepatic encephalopathy include:
- Hepatocellular failure
- Severe liver injury
- Increased serum ammonia levels from a high-protein diet, GI bleeding, uremia, or bacterial growth in the intestine
- Development of a portal shunt directly from the portal circulation to the systemic venous system
Assessment Of The Need For Long
Patients with cirrhosis are at risk of developing new episodes of encephalopathy. Several factors need to be considered:
Diet and Nutrition
Low-protein diets are often erroneously recommended for patients with cirrhosis, in hopes of decreasing intestinal ammonia production and of preventing exacerbations of HE. An obvious consequence was the worsening of preexisting protein-energy malnutrition. Protein restriction may be appropriate in some patients immediately following a severe flare of symptoms . However, protein restriction is rarely justified in patients with cirrhosis and persistent HE. Indeed, malnutrition is a more serious clinical problem than HE for many of these patients.
It is the infrequent patient who is intolerant of a diet high in protein. Most patients with mild chronic HE tolerate more than 60 to 80 g of protein per day.
Diets containing vegetable proteins appear to be better tolerated than diets rich in animal protein. This may be because of increased content of dietary fiber, a natural cathartic, and decreased levels of AAA. AAA, as precursors for the false neurotransmitters tyramine and octopamine, are thought to inhibit dopaminergic neurotransmission and worsen HE. Ingestion of red meat protein should be discouraged.
Control of Potential Precipitating Factors
Higher Likelihood of Recurrent Encephalopathy
Assessment of the Need for Liver Transplantation
Hepatic Encephalopathy and Fitness to Drive
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Comparison Of Treatment Groups
The 2 groups were similar with respect to demographics and clinical features . The precipitants of HE included a total of 80 potential contributing factors identified in 50 patients . Admission laboratory data were also similar in the 2 groups , with the exception of blood urea nitrogen level, which was higher in the PEG group . Admission ammonia levels were elevated in both groups . Nineteen patients in the lactulose group and 18 patients in the PEG group underwent head computed tomography scanning. No acute CT findings were identified in any patient.
Why Is Lactulose Used For Hepatic Encephalopathy
Hepatic encephalopathy is a medical condition that is characterized by mental disorders in patients with chronic liver diseases or portal hypertension. In hepatic encephalopathy there is buildup of toxins in the brain, which leads to neurological and psychological symptoms in patients suffering from this condition. This could be attributed to impaired liver function due to various causes such as cirrhosis, portal hypertension, liver failure, Reyes disease, infection, hypovolemia or dehydration, constipation, electrolyte imbalance due to diuretics causing hypokalemia or hyponatremia, sedatives such as barbiturates or benzodiazepines, nitrogen overload in the gut or renal failure.
The symptoms of hepatic encephalopathy range from mild to severe depending on the above underlying causes. These include sleep disturbance, confusion, forgetfulness, mood swings, memory problems, lethargy, slurred speech, deterioration of motor skills such as writing or driving, tremors, changes in personality and behavior, irritability, apathy, disorientation, stupor, drowsiness, coma and even death if underlying disease is not managed on time.
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Hepatic Encephalopathy And Lactulose
What is hepatic encephalopathy?Hepatic encephalopathy is a complication of liver disease that occurs when blood flow bypasses the liver and enters into the rest of the circulation. This unfiltered blood carries toxins that enter the brain and affects normal function. This toxic effect on the brain is called encephalopathy which can be seen as altered level of consciousness, altered intellectual function or changes in personality/behavior. Muscle and reflex abnormalities are also present. These changes can range from mild to severe .
Some symptoms include poor memory, confusion, sleepiness, being awake during the night and sleeping during the day, irritability and tremor. Encephalopathy is most commonly a complication of cirrhosis but can also occur in some other conditions.
How is hepatic encephalopathy treated? LactuloseThe toxins that enter the brain are byproducts of the foods we eat and are also produced by the normal bacteria in the large intestine. Thus treatment is aimed at decreasing the amount of toxins that can be absorbed from the large intestine. Lactulose alters the acidity in the colon which prevent absorption of ammonia, one of the toxins.
The correct dose of lactulose varies from one person to the next and it may change from day to day for each individual. The correct dose will cause 3 to 4 loose bowel movements per day. Depending on what you eat, it may be necessary to alter the dose each day.
High Blood Ammonia Levels In Liver Cirrhosis
Ammonia is a substance that is made in our bodies as a by-product of various metabolic processes. Ammonia is toxic to your nervous system at high levels, but the levels of it in your blood are normally kept under control by your liver, which stops ammonia from entering your circulation by converting it into other substances. Your muscles are also able to remove ammonia from the blood.1
In advanced liver disease, dysfunction of the liver and wasting of the muscles means that both of these important ammonia-clearing processes are impaired. Ammonia levels start to build up in the blood and contribute to the development of HE.1
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Identification And Removal Of Precipitating Factors
When there is obvious worsening of HE , a vigorous search to identify and eliminate a precipitating factor or factors should be instituted.
In most cases of cirrhosis with acute or chronic HE, a precipitating factor is found, such as the following:
GI hemorrhage. Exploration requires stool analysis and/or placement of a nasogastric tube.
Infections. This factor requires culture of all appropriate body fluids blood, urine, ascites, and pleural fluid when present. Spontaneous bacterial peritonitis and pneumonia may present with HE.
Use of psychoactive medication. This factor may require a urine screen for benzodiazepines, narcotics, and other sedatives.
Constipation. Noncompliance with lactulose doses at home.
Renal and electrolyte disturbances. These include renal failure, metabolic alkalosis, hypokalemia, dehydration, and diuretic effects.
Acute deterioration of liver function in cirrhosis. HE in cirrhosis seldom reflects the acute impact of liver failure. Exceptions include the presence of superimposed alcoholic hepatitis, the development of an acute circulatory disturbance , and the impairment of liver function seen after surgery in cirrhosis.
TIPS. Precipitating events should also be sought with the development of encephalopathy after placement of TIPS for control of portal hypertension.
Spontaneous encephalopathy should raise the suspicion of an abnormal collateral circulation imaging of the abdomen should be performed looking for spontaneous splenorenal shunt.
Side Effects Of Lactulose
Bloating, gas, nausea, stomach pain, cramps, and burping may happen. If they persist or gradually worsen please notify a pharmacist or doctor immediately.
Remember that the doctor prescribed this drug after weighing the pros and cons and judged that there are higher chances of a benefit than developing side effects. The majority of the people who used this lactulose medication do not experience its side effect so the chances are slim.
However, if you notice any of the following severe side effects seek urgent medical attention. The symptoms are vomiting, diarrhea, seizures, irregular heartbeat, muscle weakness and cramps, and mood changes.
Developing severe allergy is highly unlikely but if it does happen then run to a doctor. The symptoms of a severe allergic reaction are itching/swelling, severe dizziness, rash, difficulty in breathing.
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Manage Triggers & Coexisting Problems
- Mild to moderate hyponatremia is often seen upon admission . This may sometimes function as a precipitating cause of hepatic encephalopathy.
- Lactulose alone is generally a very effective treatment for both hyponatremia and also hepatic encephalopathy.
- Lactulose is an osmotic cathartic agent, so it removes water from the body and increases the sodium concentration.
- This commonly develops during treatment of hepatic encephalopathy, as a side-effect of lactulose therapy.
- Hypernatremia must be managed aggressively , otherwise it will contribute to the patient’s encephalopathy and agitation.
- For patient who require ongoing treatment with a cathartic, switching from lactulose to polyethylene glycol may reduce free water losses and thereby facilitate effective treatment of hypernatremia.
- Hypokalemia may increase ammonium reabsorption by the kidneys, potentially exacerbating hepatic encephalopathy.
- Adequate renal function is essential to allow patients to clear toxins and emerge from encephalopathy.
- Renal function should be supported aggressively .
- If the kidney starts failing, consider aggressive support.
Treatments To Increase Ammonia Clearance
Zinc. Low zinc concentrations are common in patients with cirrhosis of the liver, particularly those with HE. Even in patients who are not zinc deficient. Patients with fulminant hepatic failure and subacute hepatic failure have also been shown to have low serum zinc levels. Zinc deficiency also leads to alteration of neurotransmitters like GABA and norepinephrine. Zinc supplementation has been tried in HE. It may have a role in mild chronic HE, though further trials are necessary.
Unequivocal evidence of benefit of oral zinc therapy for treatment of acute HE is lacking. Zinc sulfate and zinc acetate have been used at a dose of 600 mg orally every day in clinical trials. HE improved in two studies there was no improvement in mental function in two other studies. However, an interesting study from Japan in 2010 showed zinc supplementation significantly improved patients’ quality of life, as it improved the physical component scale but not the mental component scale. Zinc supplementation also significantly decreased HE grade and blood ammonia levels and improved Child-Pugh score and neuropsychological tests compared with standard therapy. Interestingly this study showed as well administration of zinc in combination with L-carnosine showed to enhance intestinal barrier and improve zinc plasma levels.
Some examples for probiotics available in USA that contains same species that showed some effect for HE include :
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Why Is This Medication Prescribed
Lactulose is a synthetic sugar used to treat constipation. It is broken down in the colon into products that pull water out from the body and into the colon. This water softens stools. Lactulose is also used to reduce the amount of ammonia in the blood of patients with liver disease. It works by drawing ammonia from the blood into the colon where it is removed from the body.
This medication is sometimes prescribed for other uses ask your doctor or pharmacist for more information.
If You Forget To Take It
If you forget a dose of lactulose, just skip the missed dose and take your next dose at the usual time.
Never take 2 doses at the same time. Never take an extra dose to make up for a forgotten one.
If your doctor has told you to take lactulose every day and you often forget doses, it may help to set an alarm to remind you. You could also ask your pharmacist for advice on other ways to help you remember to take your medicine.
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