Liver

Question 1

acute hepatic failure, acute liver failure(ALF), or fulminant hepatic failure (FHF) are all the same things, t or f

Answer 1

true

Question 2

**what does fulminant mean

Answer 2

a disease that has rapid and sudden onset

Question 3

normal functioning of the liver

Answer 3

neutralizes toxins and waste and the cleaning of blood throughout the entire body

Question 4

when we have pressure on the diaphragm due to inflammation of the liver, what is the pt predisposed to

Answer 4

respiratory problems

Question 5

someone in acute liver failure has other dysfunctions what are they

Answer 5

hemodynamic instability - coagulopathies - high risk of bleeding making them predisposed to shock (hypo-volemic shock)
high risk for respiratory insufficiency/failure
risk for perfusion abnormalities
risk for renal failure
high risk for impaired immune responses and infection making them at high risk for infection then sepsis

Question 6

why is the liver different r/t where it receives it blood supply

Answer 6

most vital organs get blood from arterial system

the liver gets it blood supply from arterial system (1/3) and venous system (2/3) making it a low pressure organ

Question 7

what does we mean by a low pressure organ (liver)

Answer 7

inflammatory process causes decreased perfusion to the liver resulting in hypo-perfusion and high risk portal hypertension
+ ascites causes pressure on diaphragm causing resp problems - high risk for intravascular fluid depletion - decreased circulating blood volume due to low albumin causing fluid shift into abdomen - hypovolemia with ascites

Question 8

if the liver fails acutely what are we going to have problems with

Answer 8

shock - sepsis - hypovolemia and bleeding

Question 9

Acute hepatic failure defined as

Answer 9

Rapid deterioration of liver functioning (includes coagulopathies)
Coagulopathies result in bleeding and hemorrhage
Changes in mental status r/t decreased albumin and increased ammonia - increased ammonia levels cross the blood-brain barrier and causes severe confusion
Acute onset - no previous hx of chronic liver dysfunction

Question 10

number 1 cause of acute hepatic failure

Answer 10

acetaminophen (Tylenol) overdose

Question 11

additional cause of fulminant liver failure

Answer 11

Hep B or C exposure (second leading cause) or “Viral”
Tylenol overdose
ingestion of wild mushrooms thought to be edible

Question 12

what is the antidote to Tylenol overdose

Answer 12

acetylcysteine N (Mucomyst)

Question 13

Intervention for ALL HEPATIC FAILURE REGARDLESS OF CAUSE

Answer 13

acetylcysteine N (Mucomyst) - shown to improve outcomes

Question 14

what should we ask a pt w/chg in LOC, bruising and bleeding with no previous hx of cirrhosis or liver dysfunction and the pt may be jaundice

Answer 14

assess exposure to all prescription and OTC meds (amoxicillin and ampicillin in children)
exposure to HEP B and C
what have they eaten - were they in Europe
assess alcohol consumption

Question 15

definitive treatment for fulminant hepatic failure (FHF)

Answer 15

*liver transplant

mars is used as a bridge to transplantation

Question 16

necrosis of cells results in

Answer 16

high risk for SIRS likely to result in MODS and ARDS - within 3-8 weeks - rapid process

Question 17

what do we base fluid resuscitation on

Answer 17

BP - MAP

Question 18

manifestations of acute hepatic failure

Answer 18

Destruction of liver cells - coagulopathies - PT60-100 - INR - 1.5 or > super high-risk of bleeding
Hyperbilirubinemia (definitive dx tool) - jaundiced - unconjugated because the liver conjugates bilirubin
Hypoglycemia - depression of glucose synthesis
Decreased lactate clearance - worsens metabolic acidosis - give NORMAL SALINE

Question 19

normal lab values r/t liver fxn tests (lab)

Answer 19

INR - 0.8 - 1.2
PT - 10-14 sec
clotting factors are not normal in FHF

Question 20

how do we assess coagulopathies in liver failure

Answer 20

PT and INR

Question 21

FHF fulminant hepatic failure occurs over this period of time

Answer 21

1-3 weeks - confusion, bruising

Question 22

hepatic encephalopathy (chg in mental status) can occur

Answer 22

as soon as 2 weeks after the onset of disease

Question 23

within 6-8 weeks of onset of FHF patients are

Answer 23

in a coma, dead or in need of a transplant

Question 24

in hepatic encephalopathy there are how many stages

Answer 24

4

Question 25

stage 1 coma grade s/s

Answer 25

mild confusion, slurred speech, normal EEG

Question 26

**stage 2 coma grade s/s

Answer 26

mild confusion, lethargy, marked asterixis

Question 27

stage 3 coma grade s/s

Answer 27

marked confusion, incomprehensible speech

Question 28

stage 4 coma grade s/s

Answer 28

responsive to deep stimuli to no response, coma

Question 29

how can we assess stage 4 coma

Answer 29

there is no gag reflex when suctioning patient when they are on the ventilator

Question 30

lab studies to know r/t FHF - fulminant hepatic failure

Answer 30

hyperbilirubinemia
liver enzymes (AST, ALT) are HIGH
serum ammonia levels are HIGH
**Albumin is LOW
PT, INR are HIGH
ABG - initially respiratory alkalosis progress to metabolic acidosis - initially hyperventilate, after increased WOB and hypoxemia dx as resp failure then increased PaCO2 - must be ventilated
Platelets are LOW - called thrombocytopenia - give vitamin K norm

Question 31

treatment for resp failure with high PaCo2

Answer 31

increase resp rate on ventilator to blow off excess CO2

Question 32

s/s with hepatic encephalopathy

Answer 32

confusion, headache, jaundice, personality chgs, palmar erythema, edema, spider nevi, liver flapping

Question 33

ammonia directly correlates to

Answer 33

worsening of encephalopathy - get levels down

Question 34

how do we decrease ammonia levels

Answer 34

lactulose - traps ammonia and propels it out

neomycin - decreases bacterial flora of the intestine thereby decreases ammonia formation

Question 35

complications r/t encephalopathy

Answer 35

high risk for GI bleed - give PPI prophylactic

Question 36

before the pt gets a central line what do we want to give

Answer 36

vitamin K - they have a big risk of bleeding

Question 37

how do you give vitamin K

Answer 37

sub q, IM, IV, PO

Question 38

mgmt for liver pt

Answer 38

protect pt from injury -bed low, seizure pads, 3 side-rails up, 1:1
neuro assessment q1hr
assess for resp failure
educate pt and family - scared