Hepatic Encephalopathy and Lactulose question

[thinkaboutit]

A question for those with more experience:

I'm a new nurse on an organ transplant floor. We often get patients with hepatic encephalopathy. Our MDs manage them with lactulose and rifaximin. Orders for lactulose include enemas to start and then PO. However, the PO lactulose order is often written q4 with the comment "titrate to 4-5 BMs daily."

In caring for one of my patients, I noted that there were 5 good BM's in the last 8 hours and the last 3 were watery as expected. So I skipped the next scheduled dose per the titration order. The patient then had two more (smaller) water BM's before the next dose so I skipped that one as well since he was still having output. I'm on nights. When I passed off to morning shift, I was told (read: yelled at) that I did the wrong thing by skipping doses. That nurse said I should give every scheduled dose to get the ammonia out as quickly as possible. I pointed out that I was following orders as written. I even checked with my charge nurse before omitting doses.

I've done some research since then and the literature doesn't seem to support overuse of lactulose to the point of extreme diarrhea. In fact, some of the literature I ran across suggests that inducing severe diarrhea in HE patients can further exacerbate altered mental status by making electrolyte imbalances worse.

Anyone have thoughts about or experience with this? I'm happy to give every dose of lactulose if that works but my preference in this case would be to follow orders as written. Plus, common sense seems to tell me that extreme diarrhea can't be good.

(Note: The patients with HE on my floor aren't comatose or anything - those patients are in ICU)