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Take Action Against Acute Liver Failure By Gloria J. Gdovin, RN, CCRN, TNCC, MSN Nursing made Incredibly Easy! September/October 2009 2.3 ANCC contact hours Online: www.nursingcenter.com © 2009 by Lippincott Williams & Wilkins. All world rights reserved. Statistics Affects 2,000 Americans each year Mortality is as high as 80%; in the absence of liver transplantation, patients with nondrug-induced acute liver failure will either completely recover or die within days Prognosis is especially poor for patients younger than age 10 and those over age 40 Outcomes are worsened with obesity Increased risk in patients with diabetes The Liver Located in the right upper quadrant of the abdomen The largest internal organ; has a dual blood supply Divided into left and right lobes; right lobe further divided into caudate and quadrate lobes Within the lobes are lobules consisting of hepatocytes, or liver cells Critical functions: • Bile production • Metabolic detoxification • Metabolism of nutrients, vitamins, and minerals • Synthesis and deactivation of clotting factors Picturing the Liver Cross Section of a Liver Lobule Acute Liver Failure Characterized by massive necrosis of hepatocytes The liver is initially enlarged during the acute inflammatory stage; ultimately, it atrophies as hepatocellular necrosis advances Defined by the American Association for the Study of Liver Diseases as: • evidence of coagulation abnormality • usually an international normalized ratio greater than or equal to 1.5 • any degree of mental alteration (encephalopathy) in a patient without preexisting cirrhosis and with an illness of less than 26 weeks’ duration Hepatic Encephalopathy May consist of reversible metabolic encephalopathy, brain atrophy, cerebral edema, or any combination of these Mechanisms may include the effects of cerebral edema, impaired cerebral perfusion, and impairment of neurotransmitter systems Metabolic factors are also implicated, especially ammonia and impaired circulation of amino acids Ammonia is considered the primary neurotoxin precipitating hepatic encephalopathy; levels are increased in approximately 90% of patients experiencing this symptom Drug Toxicity and Other Causes Acetaminophen toxicity is the leading cause of acute liver failure The second leading cause of acute liver failure is idiosyncratic drug reactions Other causes include: • Infection • Injury • Parenchymal disease • Vascular abnormalities (Budd-Chiari syndrome) • Fatty liver of pregnancy • Primary graft nonfunction following liver transplant Signs and Symptoms Fatigue Dark urine Weakness Light-colored stools Nausea Itching Anorexia Malaise Jaundice Right upper quadrant pain Bloating Advanced Signs and Symptoms Hyperventilation, respiratory alkalosis, and respiratory failure Hepatic encephalopathy with rapid progression to hepatic coma Profound coagulopathy Hypoglycemia Hepatorenal syndrome (reversible acute renal failure brought on by acute liver failure) Sepsis with metabolic acidosis Intracranial hypertension and brainstem herniation Hyperdynamic circulation (an increase in BP and pulse, often leading to sinus tachycardia) Systolic ejection murmur Eventual cardiovascular collapse Diagnostic Tests Lab studies will show: • Increased liver enzymes • Increased blood urea nitrogen and creatinine levels; decreased glucose level • Prolonged prothrombin time and international normalized ratio • Decreased hemoglobin and hematocrit, along with a decrease in white blood cells Body fluid cultures, serologic hepatitis tests or autoimmune markers, urine toxicology screens, tests to ascertain HIV status, and stool guaiac tests may be ordered Chest X-rays, computed tomography scans, and cerebral perfusion scans may also be ordered Pharmacologic Management Prompt administration of N-acetylcysteine should be performed for acetaminophen overdose; carnitine should be administered for valproate overdose Elevated ammonia levels will require the administration of lactulose Signs of infection or sepsis require the prompt administration of antibiotics Stress ulcer prophylaxis should be initiated Fresh frozen plasma is indicated for active hemorrhage Other Treatments For associated renal failure: Hemodialysis For hepatorenal syndrome: Administration of sympatholytic agents to reduce renal vascular tone and renal vascular resistance and norepineprine with albumin infusions to increase mean arterial pressure For refractory ascites: Transjugular intrahepatic portosystemic shunt For bleeding from esophageal or gastric varices: esophagogastroduodenoscopy and sclerotherapy; octreotide and vasopressin Liver Transplantation Most common, and successful, treatment available for acute liver failure patients. Survival rate is 65% to 80% Transplant liver from cadaver or living donor Living donor gives 60% of liver; matched by age, size, and blood type (usually donor is between ages 21 and 45) Postop period includes monitoring for primary functioning of the liver, improvement in mentation and lab results, and signs of infection Picturing Donor Liver Transplantation Patient Care Patient should be monitored in the ICU and contact with a transplant center made Goals of care include: • Optimize liver function • Monitor and treat complications correct metabolic abnormalities • Stabilize the patient for liver transplant, if appropriate Patient Care Complete a thorough history on admission, including the patient’s risk factors for liver disease and a timeline outlining the onset of signs and symptoms Assessment should include identification of any of the following: • Jaundice • Spider angiomata • Bruising or hematomas • Changes in mental status • Splenomegaly or hepatomegaly • Ascites Patient Care Monitor for any normalization or worsening of liver, kidney, and neurologic functions and vital signs Monitor for signs of coagulopathy and provide corrective treatments, as ordered Assess for signs of infection or active and occult bleeding Observe for signs of multiple organ failure, which may occur secondary to sepsis Maintain scrupulous infection control practices to prevent hospital-acquired infection Patient Care Position the patient with the head of the bed at 30 degrees for prevention or treatment of elevated ICP Monitor skin integrity for breakdown and reposition the patient frequently per your facility’s policy Maintain scrupulous skin care and protection to guard against scratching due to the itching of jaundice Maintain nutrition through the use of special enteral and parenteral solutions; control protein intake Mechanical ventilation may be needed for the patient with hepatic enchepalopathy Patient Care Meeting the psychosocial needs of the patient and his family is essential due to the profound acuity of the illness Discuss the potential need for transplant and end-oflife care Collaboration with social and chaplancy services may be helpful Ongoing psychosocial support should be provided, especially if the patient’s condition deteriorates or if he doesn’t respond to treatment