Hepatic Failure

• Understand the causes of hepatic failure and prepare for treatment to be initiated.
• Determine the stage of hepatic failure through clinical presentation and diagnostic testing.
• How nurses can manage hepatic failure and arising complications promptly for effective treatments to be initiated.

The liver performs many important functions including the formation of blood proteins that aid in clotting, transporting oxygen, and supporting one’s immune system. 

The liver is also important in the production of bile, a substance needed to help digest food, and assists one’s body to store sugar (glucose) in the form of glycogen.  Another important function of the liver is that it aids in ridding one’s body of harmful substances in the bloodstream, including drugs and alcohol and also breaks down saturated fats and produces cholesterol.

Hepatic failure occurs when one’s liver is not working well enough to perform these tasks and it can be a life-threatening emergency that requires immediate medical attention.  It can be acute or chronic, leading to hepatic coma or hepatic encephalopathy

Causes of Hepatic Failure

There are many different conditions and diseases that can contribute to hepatic failure and they are listed below.

• Liver cirrhosis
• Hepatitis A, B, and C
• Epstein-Barr virus
• Viral infections
• Cocaine abuse
• IV drug abuse
• Acetaminophen toxicity
• Repeated environmental and hepatotoxin exposure
• Hypoperfusion of the liver
• Malignant disease
• Metabolic diseases, such as Wilson’s disease and Reye syndrome
• Autoimmune disorders
• Postoperatively due to conditions such as jejunoileal bypass, partial hepatectomy and liver transplant failure
• Other conditions such as malnutrition, diabetes mellitus, chronic cholestatic disease, and hypertriglyceridemia

Clinical Presentation and Diagnostic Testing

Clinical Presentation

The patient with hepatic failure may present with the following signs and symptoms:

• Pruritus
• Jaundice
• Ascites and edema
• Abdominal pain
• Malnutrition
• Nausea, vomiting, and anorexia
• Fatigue, weakness, and confusion
• Hyperventilation, respiratory alkalosis, dyspnea, pleural effusion, crackles, and hypoxemia
• Electrolyte imbalances such as hyponatremia, hypernatremia, and hypokalemia
• Palmar erythema, spider nevi, spider angiomas, and bruising – the patient also becomes prone to bleeding
• Asterixis – occurs when the patient extends the arms, he/she cannot maintain the posture and the wrist dorsiflexes downwards involuntarily.
• Hypoglycemia and metabolic acidosis
• Gallstones, dark urine, light or clay-colored stools
• Steatorrhea – fat and greasy, foul-smelling stools
• Diarrhea
• Hepatic encephalopathy – may cause symptoms such as drowsiness, confusion, delirium, coma, inappropriate behavior, and day and night reversal. It can also cause fetor hepaticus – a sweet, slightly fecal breath odor.

Diagnostic Testing

The diagnostic tests that are typically ordered for a patient with hepatic failure include the following:

• Liver CT scan or ultrasound
• Serum chemistries, bilirubin, total protein, and albumin
• CBC and platelets
• ABGs or pulse oximetry
• AST, APT, ALT, and cholesterol
• Serum ammonia levels
• ECG to detect arrhythmias
• PT, PTT, and INR
• Plasmin, plasminogen, fibrin, and fibrin-split products
• Urinalysis, urine bilirubin, and urine urobilinogen
• EEG to assess brain function

Management and Complications of Hepatic Failure

Management

To manage the patient effectively with hepatic failure, the following steps need to be initiated:

• Administer lactulose, either orally or rectally, to lower ammonia levels because it is mostly cleared by the liver. When the liver does not work well, unmetabolized ammonia is built up causing neuropsychiatric toxicity and encephalopathy.
• If not contraindicated, administer neomycin either orally or rectally to the patient to reduce the production of ammonia.
• For the patient with ascites, administer Lasix (Furosemide). Monitor daily input and output.
• Prepare the patient for paracentesis – a procedure to withdraw peritoneal fluid with a slender needle.
• Monitor the patient’s abdominal girth. Check daily fluid input and output.
• Monitor the patient for cardiac dysrhythmias.
• Give stress ulcer prophylaxis to the patient. Keep the head of the bed elevated at 20° – 30°.  Keep a close watch for any symptoms of gastric bleeding.  Perform gastric surgery when needed.
• In patients with hepatic failure, blood clotting is altered; therefore, administer vitamin K and platelets. Be aware of the potential for bleeding and avoid frequent venipunctures.
• Administer thiamine, riboflavin, pyridoxine, and folic acid.
• Keep the patient’s blood pressure well under control.
• Monitor fluid and electrolyte levels, especially serum potassium levels. Hypokalemia can cause an increase in renal ammonia production and ammonia crosses the blood-brain barrier.  Due to this, it is essential to prevent and correct hypokalemia as soon as possible, manage electrolyte levels, and avoid administering lactated Ringer’s solution.
• Prevent infections by administering prophylactic antibiotics such as metronidazole or rifaximin.
• Assess the patient’s neurological status including mental status, level of consciousness, Glasgow Coma Scale score, and response to verbal and noxious stimuli.
• If the patient complains about a headache, check the intracranial pressure. For increased intracranial pressure, administer mannitol.
• To prevent osmotic diarrhea, consider sorbitol-induced catharsis.
• Assess respiratory status and monitor ABGs or pulse oximetry. Correct hypercapnia and hypoxemia via supplemental oxygen administration or mechanical ventilation.
• If renal failure is present, provide renal replacement therapy.
• Avoid administering benzodiazepines and other sedatives because they may mask the symptoms of liver disease. However, if sedation is required, consider giving oxazepam, lorazepam, or diazepam.  To reverse their effects, administer flumazenil – the benzodiazepine antagonist.
• For various drug administrations, adjust the dose according to the patient’s liver functions.
• Consider giving enteral feeding or TPN if the patient does not take enough oral feeding.
• Assess the patient for hypoglycemia and monitor serum albumin, electrolytes, and liver function tests.
• IV glucose may minimize protein breakdown – keep a close watch on serum glucose levels.
• To prevent intravascular volume depletion, administer IV fluids, colloids, and crystalloids, but be certain to avoid lactated Ringer’s solution.
• Keep a thorough check on serum ammonia levels. A serum concentration of 80–110 mcg/dL or 47–65 mcmol/L is normal.
• Prepare the patient for TIPS, which stands for the transjugular intrahepatic portosystemic shunt. It is a procedure in which a stent is inserted to connect the portal veins to adjacent blood vessels that have lower pressure.  This procedure helps decrease portal hypertension, prevent bleeding from varices, or decrease the formation of ascites or shunt surgery if indicated.
• If necessary, prepare the patient for a liver transplant and offer both the patient and family emotional support to cope with the disease.

Complications

Hepatic failure can lead to various complications such as the following:

• Cerebral edema, increased intracranial pressure, and low cerebral perfusion pressure
• Cardiac dysrhythmias and coagulopathy
• Respiratory depression and failure can sometimes turn into respiratory arrest
• Circulatory failure and sepsis
• Acute renal failure
• Electrolyte imbalance
• Metabolic acidosis and hypoxemia
• Gastrointestinal bleeding

Hepatic failure can also lead to hepatic encephalopathy, which can lead to death. Hepatic encephalopathy can be classified into the following types:

• Type A: hepatic encephalopathy associated with acute liver failure
• Type B: hepatic encephalopathy caused by portosystemic shunting without associated intrinsic liver disease
• Type C: hepatic encephalopathy associated with cirrhosis

The severity of hepatic encephalopathy can be graded on the following basis:

• Grade I: Euphoria, shortened attention span, or anxiety
• Grade II: Lethargy, apathy, subtle personality change, inappropriate behavior, and minimal disorientation to time or place
• Grade III: Somnolence to semi-stupor, response to verbal stimuli, and confusion
• Grade IV: Coma and lack of response to stimuli

The Bottom Line

One should see his/her doctor if any potential signs of hepatic failure are present.  The symptoms need to be reported promptly since early detection is the best key to provide accurate testing and treatment in a timely manner.  Hepatic failure can become a very serious and life-threatening illness. 

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