insulin (starting at 0.01 units/kg/hr) should be used while carefully monitoring serum glucose instead of decreasing or stopping dextrose-containing fluids Hypotonic fluid overload should be avoided, particularly in patients with hyperammonemia, because this could result in cerebral edema Increased intracranial pressure in patients with hyperammonemia should not be treated with steroids or mannitol Steroids increase catabolism and can therefore worsen hyperammonemia Mannitol has not been shown to be effective Hypertonic saline can be used