MARS: New Frontier in Acute Liver Failure
MARS: New Frontier in Acute Liver Failure
Nursing care for patients with ALF requires a multidisciplinary approach to address the many aspects of assessment, monitoring, and intervention required. Management goals focus on supporting the patient until the liver begins to recover or the patient is transitioned to transplantation. These goals include:
ICP monitoring may be initiated based on CT results and mental status changes. ICP should be kept below 20 mm Hg.
Acetylcysteine improves survival for patients with grade 1 or 2 encephalopathy and benefits patients with non-acetaminophen toxicities. Lactulose and rifaximin offer additional toxin clearance and are given by nasogastric or rectal tube to bind and excrete toxins in the gut. In patients who aren't getting MARS, CRRT can improve encephalopathy and cerebral edema by removing ammonia and other small-molecular–size particles. Patients with decreased LOC require intubation to protect the airway.
Vascular changes from circulating toxins lead to vasodilation, contributing to the need for hemodynamic support. Vasopressors may be used to maintain mean arterial pressure (MAP) above 80 mm Hg to support cerebral perfusion pressure (CPP). MAP should be kept above 70 or 80 mm Hg and CPP above 60 mm Hg. To reduce brain swelling, give hypertonic saline solution as ordered to maintain a serum sodium level of 145 to 155 mEq/L.
To help prevent increased ICP and brain herniation, position the patient with the head upright to help prevent coughing and gagging. As ordered, minimize high positive end-expiratory pressure and use low-tidal–volume ventilation. Be aware that mild hypothermia (32° to 34° F [0° to 1.1° C]) cools the brain, decreasing oxygen demand. Avoid sedation, if possible; if it's needed, expect the physician to order short-acting propofol. Keeping the patient stable requires fluid management, monitoring of infection and metabolic parameters, nutrition maintenance, and prompt recognition of GI bleeding. Perform regular neurologic checks, focusing on pupillary changes, LOC, and encephalopathy.
Caring for ALF Patients
Nursing care for patients with ALF requires a multidisciplinary approach to address the many aspects of assessment, monitoring, and intervention required. Management goals focus on supporting the patient until the liver begins to recover or the patient is transitioned to transplantation. These goals include:
early identification of the cause of ALF
rapid interventions for increased intracranial pressure (ICP), coagulopathy, and encephalopathy
management of multisystemic failure.
ICP monitoring may be initiated based on CT results and mental status changes. ICP should be kept below 20 mm Hg.
Managing Encephalopathy
Acetylcysteine improves survival for patients with grade 1 or 2 encephalopathy and benefits patients with non-acetaminophen toxicities. Lactulose and rifaximin offer additional toxin clearance and are given by nasogastric or rectal tube to bind and excrete toxins in the gut. In patients who aren't getting MARS, CRRT can improve encephalopathy and cerebral edema by removing ammonia and other small-molecular–size particles. Patients with decreased LOC require intubation to protect the airway.
Hemodynamic Support and Monitoring
Vascular changes from circulating toxins lead to vasodilation, contributing to the need for hemodynamic support. Vasopressors may be used to maintain mean arterial pressure (MAP) above 80 mm Hg to support cerebral perfusion pressure (CPP). MAP should be kept above 70 or 80 mm Hg and CPP above 60 mm Hg. To reduce brain swelling, give hypertonic saline solution as ordered to maintain a serum sodium level of 145 to 155 mEq/L.
Other Interventions
To help prevent increased ICP and brain herniation, position the patient with the head upright to help prevent coughing and gagging. As ordered, minimize high positive end-expiratory pressure and use low-tidal–volume ventilation. Be aware that mild hypothermia (32° to 34° F [0° to 1.1° C]) cools the brain, decreasing oxygen demand. Avoid sedation, if possible; if it's needed, expect the physician to order short-acting propofol. Keeping the patient stable requires fluid management, monitoring of infection and metabolic parameters, nutrition maintenance, and prompt recognition of GI bleeding. Perform regular neurologic checks, focusing on pupillary changes, LOC, and encephalopathy.
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