FULMINANT HEPATIC FAILURE (ACUTE LIVER FAILURE)

Definition

 clinical syndrome of sudden and severely impaired liver function in a previously healthy person
 The generally accepted definition is that fulminant hepatic failure develops within 8 weeks after
the first symptoms of jaundice
 Patterns of the progression from jaundice to encephalopathy have been identified and have led
to proposals of time-based classifications

3 Classification

 Hyperacute - duration of jaundice before the onset of encephalopathy is 0 to 7 days

 Acute – 8 to 28 days
 Subacute - 28 to 72 days

Pathophysiology

 Loss of normal function of hepatic tissue which occurs over a short period of time
 It results in the loss of the metabolic, secretory and regulatory effects of the liver cells
 Results un the rapid accumulation of toxic substances, which then manifests in the patient as an
altered sensorium, cerebral edema, hemodynamic abnormalities and even multiorgan failure.

Etiology: refers to a wide variety of causes, of which toxin-induced or viral hepatitis are most
common

ABC’s
  Acetaminophen, hepatitis A, autoimmune hepatitis
 B Hepatitis B
 Cryptogenic, Hepatitis C
 D Hepatitis D, drugs (acetaminophen and salicylate)
 Esoteric cause – Wilson’s disease, Budd-Chiari syndrome (hepatic vein thrombosis)
 Fatty infiltration – acute fatty liver of pregnancy

Clinical Manifestation

Assessment and Diagnostic Finding

 Blood and urine tests. Results can show how well your liver works. Your doctor will also do a test
to see how long it takes for your blood to clot. When you have fulminant hepatitis, blood
doesn’t clot as fast as it should.
 Scans of your liver. Imaging tests allow your doctor to check the liver for damage, vein problems,
tumors, or other issues. You may get an ultrasound, MRI, or CT scan.
 A liver biopsy. Your doctor will remove a small piece of your liver tissue to check

Medical Management

 Supporting the patient in the ICU and assessing the indications for and feasibility of liver
transplantation are hallmarks of management. The use of antidotes for certain conditions may
be indicated such as N-acetylcysteine for acetaminophen toxicity and penicillin for mushroom
poisoning.
 Treatment modalities may include plasma exchanges (plasmapheresis) to correct coagulopathy,
to reduce serum ammonia levels, and to stabilize the patient awaiting liver transplantation, and
prostaglandin therapy to enhance hepatic blood flow
 focus on techniques that combine the efficacy of a whole liver with the convenience and
biocompatibility of hemodialysis
 The acronyms ELAD (extracorporeal liver assist devices) and BAL (bioartificial liver) have been
used to describe these hybrid devices. These short-term devices, which remain experimental,
may help patients survive until transplantation is possible
 The ELAD exposes whole blood to cartridges containing human hepatoblastoma cells, resulting
in removal of toxic substances. In the near future, similar extracorporeal circuits using
 xenografts (transplantation of organs from one species to another) may be studied as a bridge
to liver transplantation
 The BAL device exposes separated plasma to a cartridge containing porcine liver cells after the
plasma has flowed through a charcoal column that removes substances toxic to hepatocytes
 Measures to promote adequate cerebral perfusion include careful fluid balance and
hemodynamic assessments, a quiet environment, and diuresis with mannitol (Osmitrol), an
osmotic diuretic
 The use of pharmacologic neuromuscular blockade (NMB) and sedation is indicated to prevent
surges in intracranial pressure related to agitation
 liver transplantation is the treatment of choice for fulminant hepatic failure.

HEPATIC CIRRHOSIS
 chronic disease characterized by replacement of normal liver tissue with diffuse fibrosis that
disrupts the structure and function of the liver. There are three types of cirrhosis or scarring of
the liver:
o Alcoholic cirrhosis, in which the scar tissue characteristically surrounds the portal areas.
This is most frequently caused by chronic alcoholism and is the most common type of
cirrhosis.
o Post-necrotic cirrhosis, in which there are broad bands of scar tissue. This is a late result
of a previous bout of acute viral hepatitis.
o Biliary cirrhosis, in which scarring occurs in the liver around the bile ducts. This type of
cirrhosis usually results from chronic biliary obstruction and infection (cholangitis); it is
much less common.
 The portion of the liver chiefly involved in cirrhosis consists of the portal and the periportal
spaces, where the bile canaliculi of each lobule communicate to form the liver bile ducts. These
areas become the sites of inflammation, and the bile ducts become occluded with inspissated
(thickened) bile and pus. The liver attempts to form new bile channels; hence, there is an
overgrowth of tissue made up largely of disconnected, newly formed bile ducts and surrounded
by scar tissue

Pathophysiology

 Nutritional deficiency with reduced protein intake contributes to liver destruction in cirrhosis,
but excessive alcohol intake is the major causative factor in fatty liver and its consequences.
However, cirrhosis can occur in people who do not consume alcohol and in those who consume
a normal diet and have a high alcohol intake
 Other factors may play a role, including exposure to certain chemicals (carbon tetrachloride,
chlorinated naphthalene, arsenic, or phosphorus) or infectious schistosomiasis. Twice as many
men as women are affected, although, for unknown reasons, women are at greater risk for
development of alcohol-induced liver disease. Most patients are between 40 and 60 years of
age.
Clinical Manifestation

Assessment and Diagnostic Finding

 The functions of the liver are complex, and many diagnostic tests provide information about
liver function
 Enzyme tests indicate liver cell damage: serum alkaline phosphatase, AST, ALT, and GGT levels
increase, and the serum cholinesterase level may decrease. Bilirubin tests are performed to
measure bile excretion or retention; increased levels of bilirubin can occur with cirrhosis and
other liver disorders. Prothrombin time is prolonged.
 Ultrasound scanning is used to measure the difference in density of parenchymal cells and scar
tissue.
 CT, MRI, radioisotope liver scans, and elastography studies give information about liver size,
hepatic blood flow and obstruction and the presence of liver fibrosis. Diagnosis is confirmed by
liver biopsy.
 Arterial blood gas analysis may reveal a ventilation– perfusion imbalance and hypoxia.
Medical Management

 antacids or H2 antagonists are prescribed to decrease gastric distress and minimize the
possibility of GI bleeding.
 Vitamins and nutritional supplements promote healing of damaged liver cells and improve the
patient’s general nutritional status. Potassium-sparing diuretic agents such as spironolactone or
triamterene (Dyrenium) may be indicated to decrease ascites, if present; these diuretics are
preferred because they minimize the fluid and electrolyte changes commonly seen with other
agents
 An adequate diet and avoidance of alcohol are essential. Although the fibrosis of the cirrhotic
liver cannot be reversed, its progression may be halted or slowed by such measures.
 Many medications have been shown to possess antifibrotic activity for the treatment of
cirrhosis. Some of these medications include colchicine, angiotensin system inhibitors, statins,
diuretics including spironolactone (Aldactone), immunosuppressants, and glitazones such as
pioglitazone (Acto) or rosiglitazone (Avandia).
 Many patients who have end-stage liver disease (ESLD) with cirrhosis use the herb milk thistle
(Silybum marianum) to treat jaundice and other symptoms. This herb has been used for
centuries because of its healing and regenerative properties for liver disease. Silymarin from
milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects,
especially in hepatitis, alcohol-induced liver injury and hepatocellular carcinoma
 The natural compound SAM-e (S-adenosylmethionine) may improve outcomes in liver disease
by improving liver function, possibly through enhancing antioxidant function. Primary biliary
cirrhosis has been treated with ursodeoxycholic acid (Actigall, Urso) to improve liver function.

Nursing Management

 Nursing interventions are directed toward promoting patient’s rest, improving nutritional status,
providing skin care, reducing risk of injury, and monitoring and managing potential
complications

Nursing Care Plan

Nursing Diagnosis:
Ineffective breathing pattern related restriction of thoracic excursion secondary to ascites, abdominal
distention, and fluid in the thoracic cavity

Nursing Intervention: Rationale: Expected Outcomes:

1. Elevate head of bed to at least 1. Reduces abdominal - Experiences improved respiratory
30 degrees. pressure on the diaphragm status
and permits fuller thoracic - Reports decreased shortness of
excursion and lung breath
expansion. - Reports increased strength and
sense of well being
2. Conserve patient’s strength by 2. Reduces metabolic and - Exhibits normal respiratory rate
providing rest periods and oxygen requirements. (12-18b/m) with no adventitious
assisting with activities. sounds.
- Exhibits full thoracic excursion
3. Change position every 2 hours. 3. Promotes expansion and without shallow respiration
oxygenation of all areas of - Exhibits normal arterial blood
the lungs. gases.
- Exhibits adequate oxygen
4. Assist with paracentesis, TIPS 4. Paracentesis, TIPS and saturation by pulse oximetry
or thoracentesis. thoracentesis may be - Experiences absence of confusion
frightening to the patient. or cyanosis

a. Explain procedure and its a. Helps obtain patient’s

purpose to patient. cooperation with
procedures.

b. Have patient void before b. Prevent inadvertent

paracentesis. bladder injury.

c. Support and maintain position c. Prevent inadvertent

during procedure. organ or tissue injury.

d. Record both the amount and the d. Provides record or fluid

character of fluid aspirated. removed and indication of
severity of limitation of
lung expansion by fluid.
e. Observe for evidence of
coughing, increasing of dyspnea, e. Indicates irritation of the
or pulse rate. pleural space and evidence
of pneumothorax or
hemothorax.
Goal: Improved respiratory status

Nursing Diagnosis:
Excessive fluid volume related to ascites and edema formation

Nursing Intervention: Rationale: Expected Outcomes:

1. Restrict sodium and fluid intake 1. Minimizes formation of - Consumes diet low in sodium and
if prescribed. ascites and edema. within prescribed fluid retention.
- Takes diuretic agents, potassium,
2. Administer diuretics agents, 2. Promotes excretion of and protein supplements as
potassium, and protein fluid through the kidneys indicated without experiencing side
supplements as prescribed. and maintenance of normal effects.
fluid and electrolyte - Exhibits increased urine output.
balance. - Exhibits decreasing abdominal
girth.
3. Record intake and output every 3. Indicates effectiveness - Exhibits no rapid increase in
1 to 8 hours depending on of treatment and adequacy weight
response to interventions and on of fluid intake. - Identifies rationale for sodium and
patient acuity. fluid restriction.
- Shows a decrease in ascites with
4. Measure and record abdominal 4. Monitors changes in decreased weight.
girth and weight daily. ascites formation and fluid
accumulation.

5. Explain rationale for sodium 5. Promotes patient’s

and fluid restriction. understanding of
restriction and cooperation
with it.

6. Prepare patient and assist with 6. Paracentesis will

paracentesis or TIPS procedure, if temporarily decrease
indicated. amount of ascites present
and a TIPS procedure will
lower portal pressure and
thus limit the accumulation
of ascitic fluid.

Goal: Restoration of normal fluid volume

Nursing Diagnosis:
Imbalance nutrition: less than body requirements related to abdominal distention and discomfort and
anorexia

Nursing Intervention: Rationale: Expected Outcomes:

1. Assess dietary intake and 1. Identifies deficits in - Exhibits improved nutritional
nutritional status through diet nutritional intake and status by increased weight
history and diary, daily weight adequacy of nutritional (without fluid retention) and
measurements, and laboratory state. improved laboratory data.
data. - States rationale for dietary
modifications.
2. Provide diet high in 2. Provides calories for - Identifies foods high in
carbohydrates with protein intake energy and protein for carbohydrates and protein.
of 1.2-1.5 g/kg/day. healing. - Reports improved appetite
- Participates in oral hygiene
3. Assist patient in identifying 3. Reduces edema and measures
low-sodium foods. ascites formation. - Reports increased appetite;
identifies rationale for smaller,
frequent meals
4. Elevate the head of the bed 4. Reduces discomfort - Demonstrates intake of high
during meals. from abdominal distention calorie diet; adheres to protein
and decreases sense of intake recommendations.
fullness produced by - Identifies foods and fluids that
pressure of abdominal are nutritious and permitted on
contents and ascites on the diet.
stomach. - Gains weight without increased
edema or ascites formation.
 5. Provide oral hygiene before 5. Promotes positive - Reports increased appetite and
meals and pleasant environment environment and increased well being.
for meals at mealtime. appetite: reduces - Excludes alcohol from diet
unpleasant taste. - Takes medications for
gastrointestinal disorders as
6. Offer smaller, more frequent 6. Decreases feeling of prescribed.
meals (6/day). fullness and bloating. - Reports normal gastrointestinal
function with regular bowel
7. Encourage patient to eat meals 7. Encouragement is function.
and supplementary feedings. essential for the patient
with anorexia and
gastrointestinal
discomfort.

8. Provide attractive meals and an 8. Promotes appetite and

aesthetically pleasing setting and sense of well being.
mealtime.

9. Eliminate alcohol 9. Eliminates “empty

calories” and further
damage from alcohol.

10. Administer medication 10. Reduces

prescribed for nausea, vomiting, gastrointestinal symptoms
diarrhea, or constipation. and discomforts that
decrease the appetite and
interest in food.

11. Encourage increased fluid 11. Promotes normal

intake and exercise if the patient bowel pattern and reduces
reports constipation. abdominal discomfort and
distention.

Goal: Positive nitrogen balance, no further loss of muscle mass; meets nutritional requirements

Other Nursing Diagnosis for the patient with impaired liver function:

1. Activity intolerance related to fatigue, lethargy, and malaise

2. Impaired skin integrity related to pruritus from jaundice and edema
3. Risk for injury related to altered clotting mechanisms and altered level of consciousness
4. Disturbed body image related to changes in appearance, sexual dysfunction, and role function
5. Readiness for enhanced comfort related to enlarged tender liver and ascites
6. Confusion related to abnormal liver function and increased serum ammonia level
7. Risk for imbalanced body temperature: failure to maintain normal body temperature due to
inflammatory process of cirrhosis or hepatitis