Critical Care Scenarios Episode 96: Understanding ammonia, with Prem Kandiah
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Dec 24, 2025 Dr. Prem Kandiah, a neurointensivist and ammonia expert, dives deep into the complexities of ammonia physiology and its critical care implications. The discussion highlights the unique ways ammonia can affect the brain, including mechanisms of injury and the importance of timely measurement. Kandiah explores less-known causes of hyperammonemia, such as urease-producing infections and malnutrition, especially in post-bariatric patients. He also offers practical tips for accurate ammonia testing and discusses acute management strategies.
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Use Serial Ammonia Trends In Cirrhosis
- In cirrhosis an isolated ammonia level often poorly correlates with encephalopathy and is most useful when sustained or extremely high.
- Use serial measurements to judge treatment response rather than a single admission value.
Monitor Ammonia Closely In Acute Liver Failure
- In acute liver failure check and closely follow ammonia because high levels (commonly >150 μmol/L) predict cerebral edema risk.
- Treat and monitor aggressively to reduce intracranial hypertension risk.
Check Ammonia For Unexplained Encephalopathy
- In unexplained altered mental status it is reasonable to check ammonia because a normal result directs you elsewhere.
- If elevated, follow a systematic algorithm to find the cause rather than assuming liver disease.