Highlights from this issue

ABSTRACT

This is an important topic and an interesting paper to work through. Serum ammonia is important for the diagnosis and management of urea cycle disorders and acute liver failure. Based on the premise that serum ammonia levels are unreliable for the diagnosis of hepatic encephalopathy (HE) and not associated with the severity of HE in individuals with cirrhosis Aby and colleagues looked at serum ammonia ordering in adult patients presenting to a large mid-western healthcare system – 20 338 tests (8536 patients) over 5 years. 53% of the cohort had chronic liver disease, 8 patients had a Urea Cycle Disorder, 69 patients had Acute Liver Failure and 148 were on Sodium Valproate. Of the 20 338 tests, 1138 (6.5%) were ordered for a definitive, appropriate indication, while the remainder were felt to have been ordered inappropriately. There was no change in the proportions over time. This data has significant financial implications with hence the title – serum ammonia use unnecessary, frequent and costly with the need to educate clinicians regarding appropriate ammonia testing - in essence when to do and when not to do – we don’t, for example, want to miss a urea cycle disorder. There is an excellent accompanying commentary Testing for ammonia do as I say, not as we do which includes a nice table on when to test in the hospital setting (See page 275).