Hepatic failure

1. Liver Failure/ Hepatic Failure
By,
Ms. Ekta S Patel
Assistant Professor

2. LIVER FAILURE
Liver failure is an uncommon condition
in which rapid deterioration of liver
function results in coagulopathy and
alteration in the mental status(
encephalopathy ).
Liver failure indicates that liver has
sustained injury.

3. TYPES OF LIVER FAILURE
FULMINANT
HEPATIC
FAILURE
• Encephalopathy
starts within 8
weeks
Non fulminant
hepatic failure
• Encephalopathy
starts between 8
to 26 weeks

4. ACUTE LIVER FAILURE
Acute liver failure (ALF) is
a rare condition
characterized by the abrupt
onset of severe liver injury.

5. ALF
• Acute liver failure is loss of liver function
that occurs rapidly — in days or weeks —
usually in a person who has no pre-
existing liver disease .
• It's a medical emergency that requires
hospitalization .

6. INCIDENCE
• In developed country incidence is 10
cases per million people per year.
• it accounts for 6% of all deaths due to
liver disease.
• It is more common in women than in men,
and more common in white people than in
other races.

7. ETIOLOGY OF ALF
•
VIRAL
HEPATITIS
DRUG
INDUCED
HEPATOTOX
ICITY
TOXIN
RELATED
HEPATOTOX
ICITY
VASCULAR
CAUSES
METABOLIC
CAUSES

8. VIRAL HEPATITIS
Virus hepatitis may lead to hepatic failure.
Hepatitis A and B Accounts for most of the
cases.
Atypical causes of viral hepatitis and
fulminant hepatic failure include the following:
Cytomegalovirus, Herpes simplex virus,
paramyxovirus, Epstein-Barr virus

9. DRUG INDUCED HEPATOTOXICITY
• Acetaminophen is the main drug for these type
of hepatotoxicity.
• Acetaminophen (also known as paracetamol )
may lead to liver failure as a result of intentional
or accidental overdose.
• Some kind of antibiotics, antidepressants,
anaesthetic agents, Salicylates are also
associated with hepatotoxicity.

10. TOXIN RELATED HEAPTOTOXICITY
Amanita phalloides,
mushroom toxin.
Cyanobacteria toxin .
Organic solvents (eg, carbon tetrachloride).
Yellow phosphorus.

11. AMNITA PHALLOIDES

12. VASCULAR CAUSES• Liver injury caused by
insufficient blood flow
Ischemic
hepatitis./ Shock
liver
• Occlusion of hepatic
veins that drains liver
Budd chairi
syndrome .
• Blockage or narrowing
of the portal vein.
Portal vein
thrombosis.

13. METABOLIC CAUSES
Alpha1-antitrypsin . (shape and blockage )
Fructose intolerance. (Def. of aldolase B which
results in inability to convert fructose 1 phosphate
into dihydroxyacetone and glyceraldehyde. )
Galactosemia (Decreased liver enzyme to break
down )
Reye syndrome. (fatty liver+ encephalopathy )
Wilson disease. (copper accumulation )

14. MALIGNANCIES
• primary liver tumour (hepatocellular
carcinoma).
• Secondary tumour includes hepatic
metastasis or breast, lung cancer .

15. C/M OF ALF
 Hepatic encephalopathy (mental confusion,
difficulty concentrating and disorientation)
 Sudden jaundice .
 Pain and tenderness in the upper right side of
the stomach.
 Nausea.
 Vomiting.
 Melena.

16. • Ascites (accumulation of fluid in the
stomach)
• Ankle Edema (accumulation of fluid in the
legs, ankles and feet)
• Feeling ill (Malaise).
• Drowsiness.
• Muscle tremors.

17. • Bleeding easily
• Cerebral oedema
• Coma
• Brain herniation.
• Hypotension.
• Tachycardia.
• Hematemesis.

18. DIAGNOSTIC EVALUATION
• History collection.
• Physical examination.
• CBC.
• Prothrombin time (PT) . (9.5-13.5 Seconds )
• SGOT , SGPT.
• Serum billirubin level, Serum ammonia level.
• ABG.
• Serum Creatinine level,
• Serum free copper
• Ceruloplasmin level. (20-38mg/dl)(wilson diases)

19. • Blood cultures: For patients with
suspected infection.
• Viral serology: hepatitis A virus
immunoglobulin M (IgM), hepatitis B
surface antigen (HBsAg).
• Drug screening.
• Electroencephalography(EEG)
• Intracranial pressure monitoring.
• Percutaneous (contraindicated in
presence of coagulopathy) or transjugular
liver biopsy.

20. • Autoimmune markers: Autoimmune
markers (for autoimmune hepatitis
diagnosis):
A. Antinuclear antibody (ANA).
B. Anti-smooth muscle antibody (ASMA).

21. MANAGEMENT OF ALF
Treatment of acute liver failure consists
of Drugs and liver transplantation.
Pharmacological management
includes certain antidotes to reverse
the effects of ALF and various
medications to reduce ICP.
Antidotes neutralize toxic agents or
counteract any form of poisoning.

22. PHARAMACOLOGICAL INTERVENTION
Penicillin G.
Activated charcoal.
N-Acetylcysteine.
Osmotic diuretics.
Barbiturate.
Benzodiazepine.
Anaesthetic agents.

23. PENICILLIN G
• Intravenous Penicillin G is the drug of
choice for the treatment of Mushroom
Poisoning from Amanita Phalloides.

24. ACTIVATED CHARCOL
• Patients who have recently ingested A.
Phalloides activated charcoal may bind
the toxin and prevent absorption.

25. ACTIVATED CHARCOAL

26. EFFECT OF ACTIVATED CHARCOAL

27. N-Acectylcycteine
• It is the drug of choice in acetaminophen
overdose.
•

28. OSMOTIC DIUERETICS
• Intracranial hypertension in acute liver
failure managed by osmotic diuretics such
as Mannitol.
• Mannitol decreases cerebral Edema.

29. BARBITURATE
• Pentobarbital are used when severe
intracranial hypertension does not respond
to any measures.

30. BENZODIAZEPENE
• Midazolam is used for sedation in
mechanically ventilated patients.

31. ANEASTHATIC AGENTS
• Propofol is a sedative hypnotic used to
reduce cerebral blood flow.

32. LIVER TRANSPLANTATION
When acute
liver failure
can't be
reversed, the
only treatment
may be a liver
transplant.
During a liver
transplant, a
surgeon
removes
patient’s
damaged liver
and replaces it
with a healthy
liver .
Liver
transplantation
is indicated for
many patients
with ALF.

33. COMPLICATIONS
Kidney
failure.
Cerebral
Edema.
Bleeding
disorders.
Infections.

34. OTHER INTERVENTIONS
For coagulopathy/ GIT bleeding vitamin K can
be given to treat abnormal PT.
Hypotension should be treated with fluids.
Pulmonary complications mechanical
ventilation may be required.
Head of the patient should be elevated to 30
degree .
Neurological status should be monitored
regularly.

35. NURSING DIAGNOSIS
• Increased risk of dehydration, electrolytes
and metabolic disturbances related to liver
damage.
• Increased risk of secondary infections due
to impaired immune state , related to liver
dysfunction.
• Increased risk of haematological
complications related to liver dysfunction.

36. contd
• Changes in neurological state(
Encephalopathy) due to liver insufficiency.
• Increased risk of haematological
complications related to liver dysfunction.
• Anxiety related to the symptoms of
disease and fear of the unknown.

37. NURSING INTERVENTIONS
• Assess, report and record signs and
symptoms and reactions to the treatment.
• Monitor fluids input and output closely,
observe signs of dehydration, secondary
infections, neurological disturbances, Edema
and jaundice.
• Provide adequate diet with high proteins,
carbohydrates and vitamins ( carefully in
encephalopathy) .

38. Contd.
• Administer antibiotics, antiemetic, vitamins
and other medications as prescribed, monitor
for side effects.
• Monitor for signs of possible bleeding.
• Provide prescribed diet, rest and comfort
measures.
• Provide emotional support to client and his
family , explain all procedure to decrease
anxiety and to obtain cooperation.

39. PREVENTIVE MEASURES
• Tell doctor about all medicines. Over the
counter and herbal medicines interfere
with the drugs.
• Limit the amount of alcohol.
• Do not have wild mushrooms.
• Get vaccinated for hepatitis.
• Avoid contact with other people blood or
body fluids.