Liver Failure/Transplant

Causes

Drugs (acetaminophen)

Viral (autoimmune) hepatitis (HBV)

Manifestations

Jaundice, Coagulation, Encephalopathy

Changes in cognition

Diagnostic Studies

Bilirubin - elevated

PT - prolonged

LFTs - increased

Glucose - low

CBC, Hep

Ammonia - increased

CT or MRI - Liver, ascites, or potential tumor

Grading Scale 0

Min to no changes in LOC, intellectual functioning, no flapping hand tremor G

Grading Scale 1

lack of awareness, sleep disturbances, poor attention span, personality changes and coordination

Grading Scale 2

More progressive, lethargy, drowsy, disorientated, astricus, abnormal reflexes

Grading Scale 3

Somnolent, disoriented, more confusion, flapping hand tremor, abnormal reflexes

Grading Scale 4

no arousable, comatose, unresponsive

Interventions - LOC

Transfer with Grade 1 or 2 encephalopathy since can worsen rapidly and change slowly

Hepatic encephalopathy - LOC, intellectual functioning, neurological changes or findings

Interventions

Renal function - avoid neurotoxic drugs, watch low glucose, electrolytes

Hemodynamics - fluid

Frequent Neuro exams

ICP - Mental status, pupils, motor function, v/s

Cushing triad - high bp, wide pulse pressure, low HR, irregular resp.

Other Interventions

Avoid sedatives

Low stimulation - head and neck midline

Keep comfortable

Don’t cluster activities

Know baseline behavior

NPO - risk for aspiration

Liver Transplant Assessment

Need compliance

Abstinence of smoking and alcohol

Contraindication - Liver cancer

Deceased or liver donor - needs evaluation

Liver Transplant - Post-Op complications

Bleeding, infection, rejection

Liver Transplant - Drug

Immunosuppressants - steroids, calcineurin inhibitor

Increased risk for infection and skin/lymphomas

Wear sunscreen, cover from sun

Need to report abnormal lymph node swelling

Liver Transplant - Post Operative

Electrolyte, neuro, and urine output status

Signs of bleeding, infection, rejection - assume both or either

Watch for pneumonia, atelectasis, pleural effusion

Liver Transplant - Other Post Operative

Monitor drainage from JP, NG, T tube

First 2 months critical for monitoring infection

Med adherence

Viral, fungal, bacteria causes

Gerontological Considerations

Increases with age

Risk for DILLY - drug induced toxicity

Size and metabolic breakdown decrease

Risk of Hep C

Comorbid conditions - heart, lung, may not be good candidate for transplant