• Correct/avoid potential aggravating factors, e.g. gut haemorrhage, over-sedation, hypoxia, hypoglycaemia, infection, electrolyte imbalance.

• Consider early intracranial pressure (ICP) monitoring. CT and clinical features correlate poorly with ICP though no controlled studies have yet been performed to show outcome benefit from ICP monitoring which carries its own complication rate (bleeding, infection).

• Maintain patient in slight head-up position (20-30°).

• Regular lactulose, e.g. 20-30ml qds PO, to achieve 2-3 bowel motions/day.

• Dietary restriction of protein is now not encouraged as this promotes endogenous protein utilisation.

• Hyperventilation to achieve a PaCO2 of 3.5-4kPa is often attempted but is frequently unsuccessful in achieving improvement. It may also compromise cerebral blood flow.

• Mannitol (0.5-1mg/kg over 20-30min) if serum osmolality <320m0smol/kg and either a raised ICP or clinical signs of cerebral oedema persist. If severe renal dysfunction is present, use renal replacement therapy in conjunction with mannitol.

• Sodium benzoate (2g tds PO) may be considered if the patient is severely hyperammonaemic.

• If no response to above, consider barbiturate administration, e.g. thiopental infusion at 1-5mg/kg/h, ideally with ICP monitoring.

• If still no response, consider urgent liver transplantation.

• Exercise caution with concomitant drug usage.

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