1、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: 2009 by Lippincott Williams & Wilkins. All world rights reserved.,Statistics,Affects 2,000 Americans each yearMortality is as high as
2、80%; in the absence of liver transplantation, patients with nondrug-induced acute liver failure will either completely recover or die within daysPrognosis is especially poor for patients younger than age 10 and those over age 40Outcomes are worsened with obesityIncreased risk in patients with diabet
3、es,The Liver,Located in the right upper quadrant of the abdomenThe largest internal organ; has a dual blood supplyDivided into left and right lobes; right lobe further divided into caudate and quadrate lobesWithin the lobes are lobules consisting of hepatocytes, or liver cellsCritical functions: Bil
4、e 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 hepatocytesThe liver is initially enlarged during the acut
5、e inflammatory stage; ultimately, it atrophies as hepatocellular necrosis advancesDefined 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 (enceph
6、alopathy) 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 theseMechanisms may include the effects of cerebral edema, impaired
7、cerebral perfusion, and impairment of neurotransmitter systemsMetabolic factors are also implicated, especially ammonia and impaired circulation of amino acidsAmmonia is considered the primary neurotoxin precipitating hepatic encephalopathy; levels are increased in approximately 90% of patients expe
8、riencing this symptom,Drug Toxicity and Other Causes,Acetaminophen toxicity is the leading cause of acute liver failureThe second leading cause of acute liver failure is idiosyncratic drug reactionsOther causes include: Infection Injury Parenchymal disease Vascular abnormalities (Budd-Chiari syndrom
9、e) Fatty liver of pregnancy Primary graft nonfunction following liver transplant,Signs and Symptoms,FatigueWeaknessNauseaAnorexiaMalaiseJaundice,Dark urineLight-colored stoolsItchingRight upper quadrant painBloating,Advanced Signs and Symptoms,Hyperventilation, respiratory alkalosis, and respiratory
10、 failureHepatic encephalopathy with rapid progression to hepatic comaProfound coagulopathyHypoglycemiaHepatorenal syndrome (reversible acute renal failure brought on by acute liver failure),Sepsis with metabolic acidosisIntracranial hypertension and brainstem herniationHyperdynamic circulation (an i
11、ncrease in BP and pulse, often leading to sinus tachycardia)Systolic ejection murmurEventual 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 internation
12、al normalized ratio Decreased hemoglobin and hematocrit, along with a decrease in white blood cellsBody fluid cultures, serologic hepatitis tests or autoimmune markers, urine toxicology screens, tests to ascertain HIV status, and stool guaiac tests may be orderedChest X-rays, computed tomography sca
13、ns, 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 lactuloseSigns of
14、 infection or sepsis require the prompt administration of antibiotics Stress ulcer prophylaxis should be initiatedFresh frozen plasma is indicated for active hemorrhage,Other Treatments,For associated renal failure: HemodialysisFor hepatorenal syndrome: Administration of sympatholytic agents to redu
15、ce renal vascular tone and renal vascular resistance and norepineprine with albumin infusions to increase mean arterial pressureFor refractory ascites: Transjugular intrahepatic portosystemic shuntFor bleeding from esophageal or gastric varices: esophagogastroduodenoscopy and sclerotherapy; octreoti
16、de 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
17、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 madeGoals of care include: Op
18、timize 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 patients risk factors for liver disease and a timeline outlining the onset of signs an
19、d symptomsAssessment 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
20、Monitor for signs of coagulopathy and provide corrective treatments, as orderedAssess for signs of infection or active and occult bleedingObserve for signs of multiple organ failure, which may occur secondary to sepsisMaintain scrupulous infection control practices to prevent hospital-acquired infec
21、tion,Patient Care,Position the patient with the head of the bed at 30 degrees for prevention or treatment of elevated ICPMonitor skin integrity for breakdown and reposition the patient frequently per your facilitys policyMaintain scrupulous skin care and protection to guard against scratching due to
22、 the itching of jaundiceMaintain nutrition through the use of special enteral and parenteral solutions; control protein intakeMechanical 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 illnessDiscuss the potential need for transplant and end-of-life careCollaboration with social and chaplancy services may be helpfulOngoing psychosocial support should be provided, especially if the patients condition deteriorates or if he doesnt respond to treatment,
