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
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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
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Outcomes are worsened with obesity
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Increased risk in patients with diabetes
The Liver
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Located in the right upper quadrant of the abdomen
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The largest internal organ; has a dual blood supply
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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
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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
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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
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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
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Fatigue
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Dark urine
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Weakness
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Light-colored stools
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Nausea
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Itching
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Anorexia
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Malaise
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Jaundice
Right upper quadrant
pain
Bloating
Advanced Signs and Symptoms
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Hyperventilation,
respiratory alkalosis,
and respiratory failure
Hepatic encephalopathy
with rapid progression to
hepatic coma
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Profound coagulopathy
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Hypoglycemia
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Hepatorenal syndrome
(reversible acute renal
failure brought on by
acute liver failure)
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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
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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
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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
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Stress ulcer prophylaxis should be initiated
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Fresh frozen plasma is indicated for active hemorrhage
Other Treatments
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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
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Most common, and successful, treatment available
for acute liver failure patients.
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Survival rate is 65% to 80%
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Transplant liver from cadaver or living donor
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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
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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
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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
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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
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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
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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