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A total of 371 charts were reviewed and 114 patients (levocarnitine [n=15], lactulose [n=72], and combination [n=27]) were included. No difference in the primary outcome was observed (levocarnitine [11umol/L] vs. lactulose [20 umol/L] vs. combination [23 umol/L], p=0.605). The incidence of a clinically significant reduction in ammonia levels at 48h did not differ between groups, nor did mortality. In critically ill patients with valproic acid-induced hyperammonemia, there was no significant difference in the reduction in ammonia levels in the