Transcript Recognizing & Responding To Acute Liver Failure

Recognizing &
Responding to
Acute Liver Failure
By Mary G. McKinley, RN, CCRN, MSN
Nursing2009, March 2009
2.1 ANCC contact hours
Online: www.nursingcenter.com
© 2009 by Lippincott Williams & Wilkins. All world rights reserved.
Acute liver failure (ALF)

Medical emergency

Affects 2,000 people per year in the U.S.

40% mortality rate

Rare condition that often strikes young
people
The liver wears many hats

Digestive role
- Produces bile salts for fat digestion
- Processes and stores fats, carbohydrates,
and proteins
- Processes and stores vitamins and
minerals
- Synthesizes cholesterol
- Produces triglycerides
The liver wears many hats

Endocrine role
- Regulates the metabolism of
carbohydrates, fats, and proteins
- Metabolizes hormones such as
mineralocorticoids, glucocorticoids, and sex
hormones
The liver wears many hats

Excretory role
- Excretes bile
- Excretes cholesterol
- Converts ammonia to urea
- Detoxifies drugs, hormones, and other
foreign substances
The liver wears many hats

Hematologic role
- Stores blood
- Synthesizes all but two clotting factors
- Synthesizes bilirubin
Cross section of liver lobule
Defining ALF

Evidence of coagulation abnormalities

Usually an INR of greater than 1.5

Mental alteration (encephalopathy)

All in a patient without prior cirrhosis and
illness less than 26 weeks
What ALF is not

According to American Association for the
Study of Liver Diseases (AASLD):
- ALF is the preferred term
- not fulminant hepatic failure
- not fulminant hepatitis or necrosis

AASLD recommends against using terms
related to duration of illness such as
hyperacute, acute, subacute because when
used alone, terms don’t offer clues to
patient’s progress
Common causes

Most commonly caused by toxic agents and
infectious disorders

Acetaminophen overdose is the most
common cause in U.S. and Europe

Toxic doses are highly variable; doses of
150mg/kg or 7 g have been found to be
toxic
Acetaminophen toxicity

Acetaminophen is an active ingredient in
many over-the-counter remedies, such as
cold and flu remedies

This can lead to unintentional overdose
Other triggers

The following conditions are vulnerable to
acetaminophen toxicity at lower doses:
- Chronic alcohol abuse
- Preexisting liver disease
- Malnutrition/fasting
ALF: Many causes

Infections
- Hepatitis A and B viruses
- Herpes simplex virus
- Varicella-zoster virus
- Cytomegalovirus
ALF: Many causes

Toxins
- Drugs: acetaminophen, halothane,
methyldopa, isoniazid, chronic alcohol
abuse, ecstasy
- Other toxins: sea anemone, mushroom
poisoning, carbon tetrachloride
ALF: Many causes

Injury
- Ischemia after cardiac arrest, shock,
severe heart failure
ALF: Many causes

Parenchymal disease
- Malignant infliltration: lymphoma,
melanoma, breast cancer
- Primary liver tumor
- Cirrhosis
- Wilson’s disease
ALF: Many causes

Other processes
- Vascular abnormalities such as hepatic
veno-occlusive disease (Budd-Chiari
syndrome)
- Fatty liver of pregnancy
- Primary graft nonfunction following liver
transplant
3 pathophysiologic
mechanisms of ALF

Rapidly developing hepatocellular
dysfunction

Blood flow through liver is disrupted

Cerebral edema and intracranial
hypertension
Hepatocellular dysfunction

Interrupts elimination of bilirubin

Interrupts synthesis of protein, glucose, and
coagulation factors

Due to lack of protein synthesis, capillary
oncotic pressure decreases, causing fluid
shifts from intravascular to
interstitial/intraperitoneal spaces
Hepatocellular dysfunction

Hormones such as aldosterone are not
inactivated; causes high aldosterone blood
levels

In turn, causes kidneys to retain sodium and
water and excrete potassium

End result is further fluid and electrolyte
imbalances
Disrupted blood flow
through the liver

Resistance by the liver of blood flow

Causes portal hypertension

Portal hypertension causes congestion and
engorgement of venous circulation,
especially in GI and renal systems

Engorgement can lead to: esophageal
varices, bleeding, ascites due to vascular
leak into peritoneal cavity
Cerebral edema and
intracranial hypertension

Considered most serious complication of
ALF

Cerebral edema caused by brain cell
swelling and disruption of blood-brain
barrier

Cerebral edema leads to cerebral
hypertension, which decreases perfusion;
can lead to irreversible neurologic damage
Cerebral edema

Other factors that may contribute to
encephalopathy:
- Hypoglycemia
- Sepsis
- Hypoxemia
- Seizures
Signs & symptoms of ALF

Weakness, fatigue, or malaise from
alterations in metabolism of fats, protein,
and glucose

Anorexia or poor nutritional status due to
poor GI blood flow

Bleeding/bruising from altered coagulation
factors
Signs & symptoms of ALF

Jaundice from decreased bilirubin uptake
and conjugation

Encephalopathy - characterized by CNS
disturbances ranging from lack of attention
to confusion and coma

Hypotension and fluid/electrolyte imbalance
due to decrease of plasma proteins in the
liver
Assessing a cause

Most important to identify and treat
underlying cause:
- acetaminophen toxicity can be treated with
N-acetylcysteine
-herpes virus may respond to acyclovir

Liver transplantation considered early in
therapy as patients with ALF deteriorate
rapidly with serious complications
Considering transplant

Before deciding on transplant, healthcare
team must balance likelihood of
spontaneous recovery with risks associated
with transplantation

Significant criteria for transplant: disease
etiology, age of patient, jaundice to coma
interval, serum bilirubin level, prothrombin
time, arterial pH, serum creatinine
Considering transplant

Criteria are readily available; could be used
to expedite transfer to a center and early
listing for transplant

Living donor transplantation a possibility
made necessary by scarcity of organs from
deceased donors
Considering transplant

Before liver transplantation was available,
as few as 15% of patients with ALF survived

Refinement of transplant surgery,
immunosuppressive agents, and
comprehensive care has increased survival
rate posttransplant to 65% or even 80%
Managing patient care

Number one priority: Maintain ABCs (airway,
breathing, circulation)

Elevate head of bed to facilitate breathing
and prevent aspiration

May need to administer oxygen and/or
prepare for mechanical ventilation
Managing patient care

Antiepileptic drugs may be needed to
prevent or treat seizures

Ongoing care will depend on patient’s
condition

Weakness, fatigue, and malaise: Encourage
rest with pacing of activities while
preventing complications of immobility
Nursing care

Pneumonia prevention: Encourage deep
breathing and coughing, and ambulation
- Follow infection control guidelines
- Use of incentive spirometry

Prevent venous thromboembolism - initiate
prophylaxis
Nursing care

Prevent pressure ulcers by identifying
patient at risk and implementing strategies
- Skin care
- Repositioning
- Nutrition/hydration
Nursing care

Anorexia/poor nutritional status
- Measure and record daily weights,
abdominal girth, intake and output
- Patient should have adequate amounts
of protein and vitamins
- May need to initiate enteral/parenteral
feedings early in the course of treatment
Nutritional supplementation

HepatAmine - hypertonic solution contains
crystalline amino acids
- Administered I.V.
- Provides protein, vitamins, and minerals
(such as potassium)

Vivonex Plus - enteral formula, 100% free
amino acids given orally or NG
Nursing care

Coagulation problems
- Check stool and urine for blood
- Check vital signs
- Assess lab values (CBC, INR)

Prevent GI bleeding
- Administer histamine receptor agonists or
proton pump inhibitor as ordered
- Insert NG, check gastric pH
Minimizing injury due
to bleeding

Assess fall risk and institute precautions

Institute seizure precautions

Instruct on use of safety razor and softbristle toothbrush

Administer stool softeners as prescribed

Apply pressure to all puncture sites until
hemostasis achieved
Nursing care regarding
esophageal varices

Esophagogastroduodenoscopy with
sclerotherapy may be considered
- Sclerosant such as sodium morrhuate is
injected into the varix
- Procedure has 90% success rate
Pharmacologic approaches
to esophageal varices

Ocreotide and vasopressin given with
nitroglycerin

Both medications reduce blood flow

Nitroglycerin reduces detrimental effects of
vasopressin while preserving its beneficial
effects
Sengstaken-Blakemore tube

Temporary, emergency, lifesaving measure

Others are Minnesota and Linton-Nachlas

Tubes provide tamponade at bleeding site

No longer the treatment of choice due to
respiratory compromise and/or clot
disruption following removal
Nursing care of skin integrity

Pruritus and edema associated with liver
failure

Inspect skin daily

Keep fingernails short

Avoid alcohol-based skin products
Nursing care of skin integrity

Use tepid water rather than hot

Use emollients or gentle cleansers

Minimize pressure

Maintain function with active and passive
range of motion
Nursing care of
encephalopathy

Assess level of consciousness frequently

Treatment goals include reducing excessive
blood ammonia

Lactulose decreases blood ammonia by
25% to 50%, which can improve mental
status
Reducing intracranial
pressure

Elevate head of bed for maximum cerebral outflow

Be prepared to assist with endotracheal
intubation/mechanical ventilation

Monitor vital signs frequently, especially BP

Administer antiepileptic as ordered

Group nursing interventions to minimize stimulation
Treatment of cerebral
edema

Mannitol may be ordered (osmotic diuretic)
to reduce cerebral edema and promote
diuresis

Administering short-acting barbiturate to
reduce cerebral metabolic rate

Inducing mild hypothermia to decrease
cerebral metabolic rate is controversial
Treatment of fluid and
electrolyte imbalances

Hemodynamically unstable patients may
need pulmonary artery catheter insertion to
guide fluid replacement therapy

Continuous renal replacement therapy may
be needed for patient in acute renal failure

Colloids (given judiciously) may be
administered to improve capillary oncotic
pressure and reduce third space fluid shifts
Treatment of fluid and
electrolyte imbalances

Aldosterone antagonists diuretics or
potassium-sparing diuretics may be given to
reduce fluid retention, ascites, and heart
workload

Monitor patient for volume depletion