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Hi there,

First off I am very sorry to hear about your relative. Seeing a loved one in a struggle is never an easy thing.

Hepatic encephalopathy is an indication of severely impaired liver function. Of the liver's many functions, one of them is to remove toxins from the blood. When the liver's function is impaired (as in end-stage cirrhosis) it is not able to remove toxins from even the simplest things like the protein we eat. Normally when we eat protein and the amino acids are broken down, ammonia is formed which the healthy liver rapidly clears. This does NOT happen in a severely diseased liver and the person can get confused or "encephalopathic" as they say.

The thing with severe hepatic encephalopathy, though, is that there are tons of things which can tip a person over in to confusion. These include:
a large protein meal
a gastrointestinal bleed (which is equivalent to the first one)
an infection
an electrolyte imbalance etc. etc.

Unfortunately, with every insult to the system, the person will have a hard time bouncing back because the liver itself can become further impaired with the treatments we give, thus setting up a vicious circle.

When someone has a VERY decreased level of alertness (as in hepatic encephalopathy) one can choke on his own saliva and die, so the doctors as a precaution intubated him to protect his airway and hooked him up to a ventilator. A small amount of sedation is needed when someone is on the ventilator or they instinctively start to fight it and can make the situation worse; however, this is a double-edged sword in someone with hepatic encephalopathy because the very medications given to sedate the person can prolong the recovery because the sedatives aren't as readily cleared by the liver. Unfortunately though, there is not much alternative, and as a result, the critical care doctors will attempt to sedate the person with as little drug as possible and wean as early and as quickly as they can.

If the encephalopathy is reversible, they will be able to wean down the sedation and see your relatively level of alertness. Assuming he doesn't have any problem with his lungs, they can then take the breathing tube out and see if he protects his airway from then on.

The fact that your relatively oxygen saturation went too low when they tried to wean down the sedation was probably because he started waking up a bit too much, was fighting the ventilator thus resulting in non-synchronized breathing resulting in not enough oxygen getting to the lungs.

A relative of mine has been diagnosed with this...He was found unconscious (though I have also been told he was combative at the time--not sure which is true) about four days ago. He was placed on a ventilator due to the fact that his breathing was very labored. He is on the standard treatment for this condition as far as I know (lactulose, antibiotics, etc) but has really shown no improvement. He has not regained consciousness but still is responsive to pain. He is also being given Atavan (a sedative)--they explained the reason for that as being that he needs to be sedated to be on the vent. They tried reducing the vent but his O2 saturation went down too low (I think that is what they said--having trouble understanding all this). He is to see the neurologist tomorrow and they will assess brain function.
I am getting the impression from the nurses that they do not expect him to improve. I am confused as to how they expect a person to "wake up" if he is constantly on sedatives. I know they have turned the sedatives down in order to try to wake him but he has so far not regained consciousness.
Im very worried and starting to lose hope that this can turn out well. Its been 4 days with no change. Is there anyone with experience with this out there? Is there hope that he will come out of this? Is it possible that he is no longer "there" and the only reason he is still with us is the vent? I keep reading this is a reversible condition but is it when you get to Stage 4? Any experiences/info would be greatly appreciated. Background is he has Hep C and cirrhosis/drinking and opiate use (pretty heavy). I am worried sick and still want to think there is hope but like I said, starting to think there isnt...Saw him just a week ago and he seemed OK; maybe a little out of it, which I never wouldve thought was the start of this, but I guess maybe it was...Feel bad I didnt notice or do anything...[/QUOTE]

I was just reading about your relative and I swear I am in the exact same boat with a close relative as well. Everything you wrote is exactly what we are living through with him. Can I ask how your relative is doing? Did they come out of the coma? We were told the other day we wasn't going to make it through the night. It's been 72 hours since he went to Emergency. He couldn't wake up and did not respond, got to the ER and was intubated (the tubes down his throat to breath) because his breathing was so fast...Blood pressure dropping, etc... He was not being sedated yesterday and started to go after the tubes so today he is sedated again. He also has MRSA which is an infection. That is not good when the liver and everything else is not working too good. His blood wasn't clotting and he was getting plazma. I feel there is no hope. Do you think there is? I am still trying to get him on the liver transplant list but it's been a long process. I'm not givnig up just yet. Just wondered what to expect since the doctors don't seem to give us any answers! Thank you

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