Case-Study-Cause Of Hepatic Failure

Introduction

From the given case, the major findings were that that 39 year old Mrs. Smith suffered from various disease which included cholecystisis, which refers to enlarged gall bladder. Apartfrom this she had other disorders such as severe liver failure. Suffering from these disorders she showed various symptoms like abdominal pain and episodes of fainting. She even suffered from symptoms of nausea, vomiting severe right upper quadrant and sternal pain with pressure radiating through her back. Due to a medical history of gall bladder and past experience of cholesystisis she had to undergo urgent endoscopic retrograde cholangiopancreatography (ERCP). She consumed fish and chips which is evidently high in fat and deficient in proper nutrients. Therefore this led to worsening of her liver conditions due to the high fat. In order to reduce pain she had to be administered with intraventricular opioids which are efficient in pain reduction. Additionally antiemtic was given to reduce vomiting tendencies. Her ECG was normal which showed no cardiac troubles, although the urine analysis was positive for leucocytes. The blood sugar level was 8.6 which represented a normal range, hence she was not suffering from diabetes. She had problems in breathing and fastened heart rate.

Cause of hepatic failure and metabolic pathophysiology

The major causes of hepatic failure in case of Mrs. Smith was mainly due to the continuous overuse of paracetamol and codeine. This factor was enhanced by her food habits which shows that she has been consuming nutritionally deficit, fatty foods like fish and chips. Prolonged use of paracetamol and codeine has led to the deleterious effects on the hepatic functions. Combination of codeine and paracetamol is often known commonly as codamol (Barrett& Cosa, 2018). The codamol component is a known opiate which leads to addiction towards the drug, leading to chronic use. The paracetamol component if continuously administered in higher doses can have a negative impact on the liver. It was also seen that the patient was given opiates in order to subdue acute pain. However this too has a negative impact on the hepatic functions. Most of the opioid painkillers are designed in combination with acetaminophen. The excessive use of this drug can damage liver from acetaminophen toxicity (Antiemetic agents, 2018). 

Consumption of foods such as fish and chips accelerated the liver failure process. Fish and chips is high in fat content. Additionally it lacks the nutritional components which are required for proper functioning of the immune systems. Intake of excess fat that leads to formation of fatty liver that occur due to the fat accumulation in the liver. The symptoms that were seen in the patient were related to the fatty liver problem. The common symptoms of fatty liver are poor appetite, weight loss, severe abdominal pain, physical weakness, fatigue and confusion. If the condition is not controlled it may progress towards cirrhosis causing enlarged, fluid filled abdomen, jaundice of the skin and the tendency to bleed more easily. In order to reduce further deterioration, food habits should be checked. Cholesterol should be managed. Intake of sugar and saturated fats must be reduced. Losing of weight is required along with controlling blood sugar (Bernal& Wendon, 2013).

In this case, Mrs. Smith who is suffering from acute hepatic failure should be given a regulated and monitored nutritional support. It has been observed that most patients suffering from hepatic failure often have malnutrition. This in turn becomes a risk factor for these patients. The factors which are responsible for malnutrition in patients like Mrs. Smith are an altered metabolic rate, mal-adsorption of fat, early satiety, impairment of gastric emptying and hospitalizations leading to overzealous diet therapy. Patients suffering from liver failure often are at increased risk of deficiencies of several micronutrients. For them proper level of vitamin A (25,000–50,000 IU per day), vitamin D (12,000 to 50,000 IU per day) and vitamin E (10–25 IU/kg/day) should be maintained (Li et al., 2016). Most patients with liver diseases have increased calorie expenditure. This should be kept in mind while taking care of the nutritional requirements of these patients. A suggested calorie requirement may include: Refeeding risk: 15–20 calories/kg euvolemic weight Maintenance: 25–30 calories/kg euvolemic weight Anabolism: 30–35 calories/kg euvolemic weight. Although there is a debate regarding the protein requirements of such patients especially in the end stage of the hepatic failure, but it has been seen that not only these patients require more of protein intake to keep the nitrogen balanced, however commonly tolerate normal or increased protein intake without increasing encephalopathy. The suggested provision of protein for such patients is 1.0 to 1.5 g/kg euvolemic weight as tolerated and 0.8 g/kg, if refractory encephalopathy is present (Myburgh & Mythen, 2013). Therefore several studies have shown that any unnecessary diet restrictions should be avoided in case of patents with hepatic failure. If proper medications is being administered then such restrictions in the diet is not required. Although care should be taken that the patient is taking a regular and healthy diet which should be designed in accordance to the suggested proportions of the nutritional requirements. Finally oral intake should be enhanced by providing careful attention to the personal needs of the patient.

Peritonitis and pain control

The inflammation of the peritoneum refers to peritonitis, often occurring to the perforation of the membrane lining of the abdominal cavity and the visceral covering.  Peritonitis is often the result of bacterial infection that comes from the gastro-intestinal tract. For the patients suffering from peritonitis intensive care is required. The nurses involved in care giving to such patients must assess the pain continuously. The gastrointestinal function should also be continuously monitored. The fluid and electrolyte uptake by the body should be balanced. Proper diagnosis of the pain must be carried out which is related to peritoneal irritation (Nusrat et al., 2014). Care should be given in case of decreased fluid volume that is related to major shifting of fluids towards the intestinal lumen and decrease in the vascular space. The nursing interventions that must be followed in case of peritonitis includes monitoring of the blood pressure. It is monitored by arterial line if shock is present. Administration of medications such as analgesics can help in reducing the pain. Acute monitoring of all the intakes and output must be monitored along with fluid replacement. The nurses should administer and closely monitor the IV fluids.  The character of drainage should also be monitored postoperatively and recorded. For better provision of care, the nurses must take initiatives to educate the patient and the family members about the care. The acute pain caused might have an association with chemical irritations occurring in the parietal peritoneum due as a result of toxins. It may also be caused due to the trauma suffered in the tissues. Additionally abdominal distension might occur as a result of fluid accumulation in the abdominal and the peritoneal cavity leading to acute pain (Barr et al., 2013).

In order to manage such conditions of acute pain the involved nurse should investigate the pain reports, recording the duration, intensity and characteristics of the pain. This is required since the change in location or the intensity of the pain may refer to developing complications. With the acceleration of the inflammatory process the pain has the probability of becoming consistent and spread over the abdomen as a whole. A semi-Fowler’s position must be maintained in the patient (Cho& Johnson, 2014). This helps in facilitating the circulation of fluid and wound drainage by gravity. It reduces irritation of diaphragm and abdominal tension, reducing the amount of pain. The patient should be moved slowly near the painful areas. This will help in reducing the muscle tension and guarding will help to minimize the pain occurring during movement. Some comfort measure may also be provided by the nurses like back rubs, massages and breathing. This causes relaxation and enhances the ability of the patient to cope up with the experience through refocusing the cognitive ability and attention. Regular oral care might be provided to remove noxious environmental stimuli. It helps in reducing nausea and vomiting which are linked with increased intra-abdominal pressure and pain. Analgesic medications are administered that decrease metabolic rate and intestinal irritation caused from local toxins. The ultimate result is decrease in pain and promotion of healing. In case the pain is severe it needs narcotic pain control. It might be required to stop the analgesic initial stage of diagnostic process since they hold the possibility of masking signs and symptoms. Antiemetic can also be given to address concerns such as nausea and vomiting. Lastly, antipyretics can be administered to address discomfort that is related with fever (Angeli et al., 2015). 

GI tract infection

Mainly in cases of tertiary peritonitis the GI tract is infected with multi-drug resistant (MDR) organisms like the enterococci, Pseudomonas aeruginosa, and several Candida spp. (Pelaseyed et al., 2014). The severity of the infection is influenced by the origin of the infection, the ability of the host to contain the infection and the rapidity and adequacy with which the infection is dealt with. The most common source of infection related with GI tract is the appendix followed by colon and lastly the stomach. Pancreas also serves as a major source win case of peritonitis, which sometimes can lead to mortality as compared to others. There is a population of commensal flora present in the GI tract which comprises of the anaerobes and the streptococci. Apart from this the stomach and the duodenum is generally sterile (Myburgh & Mythen, 2013). The remaining of the GI tract is predominantly colonized by the enteric aerobic and the facultative gram negative bacilli. The number of the anaerobic gram negative bacilli increases moving towards the proximal jejunum. These were isolated to see that this population of bacteria has the capacity to invade the peritoneum and thus causing peritonitis by bacterial translocation.

In order to restore the septic cascade steps needed to be taken such as controlling the source, restorating of GI tract function, antimicrobial therapy and support of the organ function. Three methods of abdominal sepsis by local mechanical management can be done, following initial laparotomy for source control included laparostomy, planned relaparotomy (PR), and on-demand re-laparotomy (ODR). Open-abdomen management involves the coverage of the abdominal contents temporarily with polyglactin mesh, towels and vacuum assisted closure (Stepanova et al., 2013). The technique is beneficial in some cases either to avoid abdominal compartment syndrome or due to physical inability to re-approximate the abdominal fascia. After infected tissue is removed, the focus is to be given to the restoration of anatomy and function of the GI tract. Antibiotics are given in order to prevent both local and haematogenous spread of infection, as well as to delay the complications. Evidence-based guidelines regarding the selection of antimicrobial therapy have been formulated by the “Surgical Infection Society”, the “InfectiousDiseases Society of America”, the “American Society for Microbiology”, and the “Society of Infectious Disease Pharmacists”. In uncomplicated cases of abdominal infection, the prime focus of infection is treated quickly and efficiently by surgical excision of the involved tissue alone, and the administration of antibiotics is unnecessary beyond preoperative prophylaxis (Runyon, 2013).

The GI tract has a primary role in digestion, in the immune system, and the production of hormones and neurotransmitters. It processes food and absorbs nutrients and water, while excreting and keeping out unwanted toxins. The lining of the intestines acts as a barrier that allows fully digested foods to pass through its lining and enter the bloodstream. The cells that line the intestines act as a filter between the environment and the body. Without the GI tract barrier, our bodies would reject all food that we ingest. The body sees food as a foreign substance. Foreign substances that produce an inflammatory immune response are known as antigens (Pelaseyed et al., 2014). The role of the GI tract is to keep out all antigens that are detrimental to the body. Antigens include food, bacteria, and toxins which all are the foreign particles for the body. Within hours after the entry of these foreign particles into the body, it will be overwhelmed by the injection of this foreign substance. Inflammation and infection would spread throughout the bloodstream to all parts of the body. It would lead to inflammation and sepsis which is total body infection. If the protein is not removed and the infection and inflammation are not treated soon enough, death would quickly ensue. The GI tract however, allows us to take in foreign substances such as animal protein on a daily basis without any inflammatory response (Wang, Yin& Yao, 2013). Therefore, the protective role of the GI barrier is critical in that it allows us to ingest the foods that we need without potential deadly consequences. 

Unfortunately, under stress this protective mechanism and other functions of the GI tract are disrupted. The GI tract contains the largest part of the body’s immune system in its mucosal lining. The GI immune systems role is to ensure that unwanted entities don’t cross the GI tract and enter the blood. The gastrointestinal tract is the first line of defence against pathogens, which enter the body through food we ingest. However, under stress, unwanted pathogens (bacteria and viruses that can cause disease), toxins, and food substances are not destroyed by the immune system and are allowed to cross the barrier, leading to infection and inflammation throughout the body (Yamashita et al., 2013).

Evidence bases guidelines

Antimicrobial Therapy

The mounting antimicrobial resistance together with increased trend of prescribing inappropriate antibiotic has resulted in a threat for the patients requiring critical care. A study showed that using inappropriate antibiotic has led to development of blood stream infections in many patients (Ferrer et al.,  2014). In case of patients like Mrs Smith who are in need of critical care, needs to be given proper antibiotics since they has already been an incident of peritonitis. Therefore care should be taken to ensure that multidrug resistant bacteria does not infect them. If this occurs removal of the sepsis from the gastro intestinal tract will become more difficult.  Some of the evidence based guidelines that should be followed for proper antibiotic therapy of the patient includes provision of rationale for antibiotic start in the patients´ charts,performance ofregulated microbiological sampling as per the terms of  local or international guidelines,prescription of empirical antibiotic therapy,reviewing diagnosis on the basis of microbiological results, evaluatingdecrease of doses on the basis of microbiological results,considering discontinuation of treatment as per the local or international guidelines and to the clinical picture. Antibiotic treatment is to be based on serum procalcitonin level. The antibiotics should be started within 4hof antibiotic treatment, without any interruption, given by the serum pro-calcitonin level. The dosage of the antibiotic is to be considered for evaluation on the basis of kidney function (Cho& Johnson2014).

Fluid therapy

In patients with acute liver diseases, the nutritional support and the fluid therapy plan should be implemented in regards to the needs of the patient. The mechanism of the disease and its characteristics, the functions of the liver, and the tolerance of the gastrointestinal tract are all responsible for determining the proper guidelines of administering proper fluid therapy in such patients (Padhi et al.,  2013). Along with the fluid therapy, the enteral nutritional support also plays a major role in patients like Mrs Smith whose gastro-intestinal function is also impaired. This provides an opportunity for the application of postoperative EN support at an early stage. This helps to maintain the structure and functional integrity of the cells of the intestinal mucosa. It also protects the barrier of the intestinal mucosa. It helps in reducing bacterial translocation and spread of intestinal infection and recovers the function of the gastrointestinal tract. The guidelines suggested that the daily dose of then fluid of total parenteral nutrition should be approximately 50 mL/kg/day for adult patients. Total Parenteral Nutrition volume should not be more than 3,000 mL for a 70 kg adult patient (Runyon, 2013). In situations of vomiting or diarrhoea and excessive drainage, the amount of liquid might be increased. Although it should be limited depending on the patient status. The evidence based guidelines for the fluid therapy includes fluid resuscitation, routine maintenance, replacement and redistribution. While administering fluid therapy certain conditions must be taken care of such as the physiology of fluid balance in health, pathophysiological effects on fluid balance, clinical approaches to assessing IV fluid needs and the properties of available IV fluids (Hadzic, 2017). 

Critical care in nursing

In order to give critical care to the patients suffering from acute liver damages, the role of the nurses to provide critical care should be of quite importance. It has been seen that in most cases the care required by the critical patients is related to viral hepatitis, and in most cases hepatitis C (Hall& Wood, 2015). The nurses should work in cooperation with a multidisciplinary team consisting of the physicians, pharmacists, hepatologists, and the social workers. The nurses involved in care giving of such patients should have a proper training in hepatology which is related to cirrhosis (McKean, 2016).  The educational interventions that are carried out for the nurses include dietary habits, exercise, self?control of heart rate and arterial pressure in patients under beta?blocker treatment, skin care in patients with leg oedema to prevent infections, sticking to the prescribed medications, judicious use of laxatives and glucose control in diabetic patients. Nursing cirrhosis consultation run by a nurse practitioner for nursing care in such cases is required accompanied by discussions with a hepatologist and referral cases (Morton et al., 2017). 

Conclusion

In conclusion it can be stated that the patient Mrs Smith has been suffering from several problems, of which the major disorders are related to gall bladder diseases and liver diseases. In order to receive relief from the acute pain that she has been experiencing as a result of hepatica failure and cholecystesis, she self-administered drugs such as paracetamol accompanied with codeine for a long time. This prolonged used of inappropriate drugs has a detrimental effect on the liver of the patient. The presence of codeine in the drug made Mrs Smith addicted to the drug which kept on increasing. Apart from taking inappropriate medicines, her metabolic intake also enhanced the deterioration of her liver conditions. As a result she suffered from malnutrition which resulted in decreased immune response of the patient. 

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