BCCCP: Hepatic Encephalopathy Critical Care Questions

Question 1 of 10

1. Question

A 62-year-old man with decompensated cirrhosis due to chronic alcohol use is admitted to the ICU for acute hepatic encephalopathy. Over the past 24 hours, he has become more confused and is noted to have asterixis. On examination, temperature is 36.8°C, heart rate is 88 bpm, and blood pressure is 100/60 mmHg. Laboratory results reveal:
• Hemoglobin 7.2 g/dL (9.8 g/dL measured 12 hours ago)
• BUN 45 mg/dL, creatinine 1.5 mg/dL
• Serum sodium 135 mEq/L
• WBC count 7,500/mm3
Stool guaiac test is positive. He is receiving lactulose via nasogastric tube. Based on these findings, which of the following is the MOST likely precipitating factor for his acute hepatic encephalopathy?

Gastrointestinal bleeding
Hyponatremia (serum sodium 128 mEq/L)
Spontaneous bacterial peritonitis
Recent benzodiazepine administration

Question 2 of 10

2. Question

A 62-year-old man with decompensated cirrhosis due to alcohol-associated liver disease is admitted to the ICU for overt hepatic encephalopathy (OHE). He is intubated, on mechanical ventilation, receiving continuous enteral nutrition via nasogastric tube, and has a central venous catheter in place. He weighs 70 kg and has significant muscle wasting noted on exam. His current albumin is 2.1 g/dL. Which of the following represents the most appropriate daily protein goal for this patient?

A protein-restricted diet of 0.6 g/kg/day (42 g/day) to minimize ammonia production.
A daily protein intake of 1.2–1.5 g/kg/day (84–105 g/day), provided as continuous enteral nutrition.
Intravenous branched-chain amino acids (BCAAs) as the primary protein source at equivalent caloric intake.
Delay protein repletion until mental status significantly improves.

Question 3 of 10

3. Question

A 65-year-old man with decompensated cirrhosis is admitted to the ICU with acute overt hepatic encephalopathy. He is intubated on assist-control ventilation, receiving a continuous propofol infusion for sedation, and has a central venous catheter. On admission, his BMI is 22 kg/m^2, and the Subjective Global Assessment indicates mild malnutrition. He tolerates continuous enteral nutrition via a gastric feeding tube. His weight is 75 kg. Which of the following is the most appropriate nutritional strategy?

Initiate a protein-restricted diet of 0.5 g/kg/day to reduce ammonia production.
Provide a daily protein intake of 1.2–1.5 g/kg, distributed evenly throughout the day with a late-night snack.
Administer intravenous branched-chain amino acid (BCAA) formulations to improve nitrogen balance.
Incorporate a higher proportion of vegetable-based proteins within the standard protein intake.

Question 4 of 10

4. Question

A 58-year-old man with decompensated cirrhosis is admitted to the intensive care unit for acute hepatic encephalopathy (HE). He is intubated on assist-control ventilation and requires a continuous norepinephrine infusion via a central venous catheter. His current weight is 70 kg. An enteral nutrition regimen providing 0.8 g/kg/day of protein was initiated upon admission. Despite receiving lactulose and rifaximin, his encephalopathy persists, though it is not refractory to medical therapy. Which of the following adjustments to the patient’s protein intake is most appropriate at this time?

Increase protein intake to 1.2–1.5 g/kg/day.
Decrease protein intake to 0.5 g/kg/day to reduce ammonia production.
Switch to a branched-chain amino acid (BCAA)-enriched enteral formula.
Discontinue enteral nutrition and initiate parenteral nutrition due to hepatic failure.

Question 5 of 10

5. Question

A 62-year-old man with decompensated cirrhosis is admitted to the ICU for worsening hepatic encephalopathy (HE). He is intubated, mechanically ventilated, and receiving a continuous propofol infusion via a central venous catheter. His family reports significant recent weight loss. His current body weight is 70 kg. Enteral nutrition is being initiated to address his malnutrition. Given this patient’s clinical status, which of the following daily protein intake goals is most appropriate?

0.5-0.8 g/kg/day to minimize ammonia production and improve mental status.
1.2-1.5 g/kg/day to prevent muscle wasting and support metabolic demands.
0.8-1.0 g/kg/day to prevent sarcopenia without increasing risk of encephalopathy.
1.8-2.0 g/kg/day to aggressively reverse sarcopenia.

Question 6 of 10

6. Question

A 62-year-old man with decompensated cirrhosis is admitted to the ICU for overt hepatic encephalopathy. He is intubated with a feeding tube placed and has been NPO due to aspiration risk. His ammonia level is elevated, and the team is planning nutritional support. Which of the following strategies is most appropriate to optimize outcomes and prevent sarcopenia?

Initiate enteral nutrition via feeding tube providing 1.2–1.5 g/kg/day of protein, using a BCAA-enriched formula if standard protein is not tolerated.
Implement a strict protein restriction of <1.0 g/kg/day to minimize ammonia production, then increase protein as mental status improves.
Administer intravenous branched-chain amino acid infusions as the primary nitrogen source to improve encephalopathy symptoms.
Provide total parenteral nutrition with glucose as the primary calorie source, withholding protein initially to prevent worsening encephalopathy.

Question 7 of 10

7. Question

A 60-year-old man with decompensated cirrhosis is admitted to the intensive care unit with overt hepatic encephalopathy. He weighs 70 kg (BMI 24 kg/m2), has a serum albumin of 2.5 g/dL, and exhibits signs of muscle wasting. He is intubated, mechanically ventilated, and receiving lactulose, rifaximin, and a continuous norepinephrine infusion. The nutrition team plans enteral feeding to prevent further malnutrition and sarcopenia while managing ammonia production. Which of the following approaches to protein intake is most appropriate?

Target a daily protein intake of 1.2–1.5 g/kg (84–105 g/day) using a standard enteral formula; consider vegetable or milk-based protein and reserve BCAA-enriched formulas for persistent intolerance.
Maintain protein restriction below 1.0 g/kg/day (< 70 g/day) to minimize ammonia production and prevent worsening encephalopathy.
Initiate intravenous branched-chain amino acid (BCAA) supplementation immediately to reduce ammonia levels and improve mental status.
Withhold enteral protein until encephalopathy resolves completely to reduce risk of intolerance and aspiration.

Question 8 of 10

8. Question

A 62-year-old man with cirrhosis due to nonalcoholic steatohepatitis is admitted to the ICU for acute-on-chronic liver failure complicated by overt hepatic encephalopathy. He is intubated on assist-control ventilation and receiving a stable low-dose norepinephrine infusion (0.05 mcg/kg/min). He has normal bowel sounds and no abdominal distension or contraindications to enteral feeding. His current weight is 70 kg (ideal body weight 65 kg), and he has been NPO for 24 hours. Lactulose has been initiated. Which of the following nutritional plans is most appropriate at this time?

Initiate continuous nasogastric enteral nutrition delivering 1.2–1.5 g protein/kg ideal body weight per day and 30–40 kcal/kg ideal body weight per day.
Implement a low-protein diet (0.6–0.8 g/kg/day based on ideal body weight) and provide glucose-based parenteral nutrition to meet 30–40 kcal/kg ideal body weight per day.
Provide enteral nutrition with 1.5–2.0 g protein/kg ideal body weight per day plus intravenous branched-chain amino acid supplementation.
Administer high-calorie parenteral nutrition (40–45 kcal/kg ideal body weight per day) with gradual introduction of protein only after resolution of encephalopathy.

Question 9 of 10

9. Question

A 58-year-old man with decompensated cirrhosis is admitted to the ICU for severe hepatic encephalopathy. Despite treatment with lactulose and rifaximin, his mental status remains markedly impaired. He is receiving enteral nutrition that provides 0.8 g/kg/day of protein. Which adjustment to his protein intake is most appropriate to optimize nutritional status and support neurological recovery?

Increase protein intake to 1.2–1.5 g/kg/day, distributed in small, frequent meals, to prevent sarcopenia and support neurological function.
Maintain the current protein intake of 0.8 g/kg/day to prevent further ammonia accumulation and worsening encephalopathy.
Implement a transient protein restriction to <0.8 g/kg/day for 24–48 hours, then slowly advance as tolerated.
Supplement with branched-chain amino acids (BCAAs) while keeping total protein intake at 0.8 g/kg/day to improve nitrogen balance.

Question 10 of 10

10. Question

A 62-year-old man with decompensated cirrhosis and recurrent hepatic encephalopathy (HE) is in the ICU, intubated and mechanically ventilated for aspiration pneumonia and Grade IV HE. He requires low-dose norepinephrine via a central line to maintain mean arterial pressure. His current weight is 70 kg (ideal body weight 65 kg). On admission, his protein intake was briefly restricted to 0.5 g/kg/day. Over the past 24 hours, his mental status has slightly improved. A nasogastric tube is in place and functional. Which of the following is the most appropriate nutritional intervention for this patient at this time? (Use ideal body weight for protein calculations.)

Initiate enteral nutrition via the nasogastric tube with a standard formula providing 1.3 g/kg ideal body weight/day of protein, continuous infusion.
Continue protein restriction at 0.5 g/kg ideal body weight/day to minimize ammonia production.
Start parenteral nutrition with a branched-chain amino acid–enriched amino acid solution providing 1.3 g/kg ideal body weight/day of protein.
Provide enteral nutrition with a standard formula delivering 0.8 g/kg ideal body weight/day of protein.