How to help patients with liver failure Your astute assessment and management can help patients survive this life-threatening condition.

By Shari J. Lynn, MSN, RN

condition, may warrant a liver transplant. • asterixis (flapping tremor) A LIFE -THREATENING liver failure results from liver dam - In a patient who does have a • peripheral edema age. In many cases, the damage is history of liver disease, ALF is • coagulopathy gradual and silent, causing few called acute-on-chronic liver fail - • dark urine symptoms until the organ loses all ure. Nonalcoholic steatohepatitis • muscle wasting of its functions. is a form of CLD caused by fat • bleeding esophageal varices Liver failure can be acute or take buildup in the liver; its exact • cerebral edema the form of chronic liver disease cause is unknown. • sepsis (CLD), which leads to irreversible ALF can be classified as hypera - • hepatic encephalopathy. end-stage liver disease (ESLD). cute, acute, or subacute based on Abnormal liver function test re - • CLD typically stems from alcohol the patient’s prognosis and time sults include an increased serum abuse, hepatitis or, less often, from onset of jaundice to enceph a - alanine level and an aminotrans - hemochromatosis (excess iron lopathy. (See Classifying ALF .) ferase level that’s 10 to 100 times stores) and malnutrition. Both ALF and CLD can lead to the upper limit of normal. Typical - • Acute liver failure (ALF) is less multisystem organ failure—quickly ly, serum bilirubin and prothrombin common than CLD. In the devel - with ALF and gradually with CLD. times are increased and the albu - oping world, it usually results To understand the effects of a fail - min level is decreased. from hepatitis B or E; in Europe ing liver, you need to comprehend Make sure to assess patients for and the United States, from acet - the mechanisms involved. (See Un - signs and symptoms of hepatic en - aminophen overdose. Other derstanding liver functions. ) cephalopathy and note their pro - causes include illicit drug use, gression. Keep in mind that in - herpes simplex virus, cyto meg a - Assessment creased confusion suggests hepatic lovirus, Epstein-Barr virus, aden - ALF and CLD share many signs and encephalopathy and cerebral ede - ovirus, and parvovirus. symptoms, including: ma. (See Grading hepatic en - ALF is a medical emergency • decreased appetite cephalopathy ). when it occurs in someone with • nausea no history of liver disease. Al - • jaundice Treatment though sometimes reversible, it • fatigue Interventions depend on whether

American Nurse Today Volume 11, Number 9 AmericanNurseToday.com 26 the patient has ALF or CLD, as Understanding liver functions well as the specific dysfunctions A highly vascular organ, the liver is perfused by 1,500 mL of blood per minute. present. (See Common dysfunc - About 75% of its blood supply comes from the portal vein and 25% from the he - tions in ALF .) patic artery. Portal-vein blood is rich in nutrients and toxins, as it comes from the GI tract and spleen. The liver detoxifies substances in the body and produces endothelin and nitric ALF treatment Treatment of ALF focuses on cor - oxide. Endothelin causes vasoconstriction; nitric oxide induces vasodilation. recting the cause. Patients require Working together, these two mediators regulate hepatic blood flow. urgent treatment and monitoring, In liver disease, portal-vein pressure rises, resulting in portal hypertension and an imbalance of endothelin and nitric oxide. Excessive nitric oxide production including serial blood and coagu - leads to splanchnic blood-vessel dilation, causing blood to shunt away from ma - lation tests. Specific measures may jor organs and increasing blood flow to the liver—in particular, the portal vein. vary with the systemic dysfunc - This shunting reduces kidney perfusion, in turn activating the renin-angiotensin- tions present. Expect invasive aldosterone system (which regulates blood pressure) as the kidneys try to in - monitoring for patients with car - crease their own blood volume. diovascular problems, such as hy - Aldosterone activation increases sodium absorption in the loop of Henle, caus - potension and intravascular vol - ing water retention and increased blood volume. Excess nitric oxide leads to dila - ume depletion, along with volume tion of abdominal vessels; at the same time, blood pressure in the kidneys de - depletion correction, vasopressors, creases. Sodium and water continue to be reabsorbed, causing circulatory volume and inotropic support, if needed. to rise—to the point that fluid leaks from the intravascular space and overloads Patients who’ve ingested acetamin - the lymphatic system. Eventually, this fluid leaks into the peritoneal cavity, result - ing in ascites, a hallmark of liver failure. ophen require I.V. acetylcysteine. In chronic liver disease, cirrhosis occurs as fibrotic tissue develops. The liver at - To reduce the risk of aspiration rophies and shrinks as more scar tissue forms. These effects are irreversible. pneumonitis, patients with a de - creased level of consciousness are likely to be intubated. Those with ing. High-grade encephalopathy CLD treatment metabolic and renal dysfunctions warrants endotracheal intubation, Treatment focuses on stopping ad - require fluid management and with partial pressure of carbon ditional liver damage and slowing blood glucose normalization, in dioxide maintained between 31 disease progression, as well as addition to possible renal replace - and 44 mm Hg and serum sodium managing symptoms. It includes a ment therapy (such as dialysis). between 145 and 150 mmol/L. In - healthy, low-sodium diet; abstaining Encephalopathy necessitates tracranial hypertension calls for from alcohol and illicit drugs; and treatment of fever and hypona - osmotherapy, temperature control, addressing medical problems as tremia, as well as sepsis screening. and rescue therapy (such as in - they occur. Ultimately, patients may Some patients may require tran - domethacin and thiopentone). An - need a liver transplant. scranial ultrasonography and in - tibiotic prophylaxis may be given tracranial pressure (ICP) monitor - to patients at high sepsis risk. Liver transplantation Patients ages 12 and older who progress to the point of needing a Classifying ALF liver transplant are assessed using the Model for End-Stage Liver Dis - Acute liver failure (ALF) can be classified as shown below. Keep in mind, though, that ease (MELD) scoring system; those these classifications have limited usefulness in clinical practice because they don’t younger than age 12 are assessed necessarily indicate prognosis. using the Pediatric End-Stage Liver Time from jaundice to Disease (PELD) system. Blood tests Classification encephalopathy Risk of cerebral edema used to determine MELD scores are serum bilirubin, serum creatinine, Hyperacute Less than 7 days Common (occurs in more than serum sodium, and international 70% of patients) normalized ratio (INR). Blood tests used to determine PELD scores are Acute 8-28 days Common (occurs in more than bilirubin, albumin, and INR. The 55% of patients) MELD score also considers the pa - tient’s renal function and whether Subacute 5-12 weeks Low (occurs in fewer than 15% of he or she is on dialysis; the PELD patients)) takes into account the child’s age and degree of failure to grow.

AmericanNurseToday.com September 2016 American Nurse Today 27 The patient’s results are entered Grading hepatic encephalopathy into a formula that yields a score. Hepatic encephalopathy occurs when an impaired liver can no longer remove toxins MELD scores range from 6 (less ill) from the blood, which causes serum ammonia levels to rise. Osmotic disturbances to 40 (gravely ill); PELD scores, then occur in the brain, along with inflammation and increased cerebral blood flow. from negative numbers to 99. A pa - Patients with hepatic encephalopathy exhibit confusion, hyperthermia, respira - tient’s MELD or PELD score can tory and circulatory problems, and increased intracranial pressure (ICP). Treatment change as his or her condition may include lactulose given by mouth or as an enema to remove ammonia through worsens. Besides reflecting the pa - the GI tract, titrated to three to four soft stools in 24 hours. Rifaximin, an antibiotic, may be used to treat infection; sodium benzoate, to decrease ammonia production; tient’s disease severity, the MELD or and hypertonic saline solution, to decrease elevated ICP. PELD score determines how urgent - Various scales have been developed to diagnose and classify hepatic encepha- ly he or she will need a liver trans - lopathy. The table below shows a system with four grades of increasing severity. plant in the next 3 months. Thus, it determines the patient’s placement Grade Signs and symptoms on the liver-transplant waiting list. Grade 1 • Mild lack of awareness Nursing care • Euphoria or anxiety Nursing care for patients with liver • Shortened attention span failure focuses on supporting body • Impaired performance of addition or subtraction systems, managing signs and symp - Grade 2 • Lethargy or apathy toms of decreased liver function, • Minimal disorientation of time or place and avoiding worsening cerebral • Subtle personality changes edema. • Inappropriate behavior • Monitor level of consciousness, • Impaired performance of addition or subtraction blood pressure, volume status, blood and coagulation tests, and Grade 3 • Somnolence to semi-stupor but responsive to verbal stimuli • Confusion signs and symptoms. • Gross disorientation • Keep the head of the bed elevat - ed 30 degrees, with the patient’s Grade 4 • Coma (unresponsive to verbal or noxious stimuli) head in the neutral position. • Decrease stimulation, such as frequent suctioning. Common dysfunctions in ALF • Stay alert for hypercapnia and hypoxia; correct these conditions Acute liver failure (ALF) leads to alterations in many body systems, as shown below. as indicated and ordered. Body system Common dysfunctions • Manage fever aggressively with a fan, cooling blanket, or both. Cardiovascular • Hypotension • Watch for signs and symptoms of • Intravascular volume depletion infection and possible sepsis; ad - • Low cardiac output minister antibiotics, as needed • Right ventricular failure and ordered. • Vasodilation • Maintain strict glucose monitor - Central nervous system • Intracranial hypertension ing for possible hypoglycemia or • Progressive encephalopathy hyperglycemia. • Provide nutritional support as or - Hematologic • Coagulopathy dered. Patients who reach an acuity Immunologic • Increased risk of sepsis level that warrants close monitor - Metabolic • Hyperammonemia ing (such as those in an intensive • Hypoglycemia care unit with grade 3 or 4 hepatic • Hyponatremia encephalopathy) require ICP mon - • Impaired drug metabolism itoring. • Lactic acidosis

Renal • Renal dysfunction Postoperative care After liver transplantation, assess Respiratory • Increased risk of aspiration pneumonitis the patient for such complications

American Nurse Today Volume 11, Number 9 AmericanNurseToday.com 28 Take steps to as bleeding, infection, and rejec - ascites, Selected references tion. Monitor the patient’s tempera - manage Bernal W, Wendon J. Acute liver failure. N ture, urine output, neurologic status which can affect Engl J Med. 2013;369(26):2525-34. and hemodynamic pressures. Also Blackmore L, Bernal W. Acute liver failure. provide education about immuno - multiple body Clin Med (Lond.) 2015;15(5):468-72. suppressive drugs. Clements A, Greenslade L. Nursing care for end-stage liver disease. Nurs Times . 2014; systems. 110(29):16-9. Managing ascites Fullwood D, Purushothaman A. Managing Liver failure commonly causes as - need follow-up fluid replacement ascites in patients with chronic liver disease. cites—fluid buildup in the peri - and albumin administration. Nurs Stand . 2014;28(23):51-8. toneal cavity. As indicated, take ap - Fullwood D, Sargent S. Complications in propriate steps to manage ascites, Rising to the challenge acute liver failure: managing hepatic en - which can affect multiple body sys - With continuing medical advances cephalopathy and cerebral oedema. Gas - tems. The physician may order di - and more patients waiting for liver trointest Nurs . 2014;12(3):27-34. uretics and a low-sodium diet. Al - donors, you’re likely to encounter Larsen FS, Bjerring PN. Acute liver failure. Curr Opin Crit Care . 2011;17(2):160-4. dosterone antagonists (such as more patients with liver failure. To National Institute of Diabetes and Digestive spironolactone) may be used to optimize outcomes, make sure and Kidney Diseases. Liver transplantation. treat ascites instead of loop diuret - you’re familiar with the signs and 2012. niddk.nih.gov/health-information/ ics (such as furosemide) because symptoms of liver failure, ascites, health-topics/liver-disease/liver-transplant/ they spare potassium and address and hepatic encephalopathy. Final - Pages/facts.aspx ascites pathophysiology. Although ly, be sure to provide emotional National Library of Medicine. Acute liver fail - patients with ascites may be placed support to patients and families . ure. Updated June 28, 2016. livertox .nih.gov/Phenotypes_fail.html on fluid restrictions, studies fail to show this intervention is effective. Patton H, Misel M, Gish RG. Acute liver fail - Shari J. Lynn in an instructor at the Johns Hopkins ure: an evidence-based management proto - Be aware that patients who under - University School of Nursing in Baltimore, col for clinicians. Gastroenterol Hepatol (NY) . go paracentesis to treat ascites may Maryland. 2012;8(3):161-212.

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