Liver Failure: Lyn Crellin

Liver Failure
Lyn Crellin
Paediatric Liver Transplant Coordinator

Victorian Liver Transplant Unit
Royal Children’s Hospital
Liver Physiology
Major functions of the liver

o Regulates blood glucose, stores energy
o Regulates blood clotting
o Produces & eliminates bile
o Neutralises and destroys toxins, drugs
o Detoxifies/eliminates – hormones, endotoxins etc
o Resists infection
o Regenerates its own damaged tissue
o Stores glucose, iron, vitamins, minerals, blood
Guyton Arthur C. & Hall John E. (2006)

Textbook of Medical Physiology 11th.
Ed., Elsevier, Philadelphia
Chronic Liver Disease 2008
Liver Disease
Arises from
o Congenital disorders
o Genetic disorders
o Medications/Drugs
o Toxins
o Infections
Inflammatory process Cirrhosis

Cirrhosis
Distorted architecture of the liver
o Necrosis
• Inflammation & cytokines release
o Fibrosis
• Formation basement membrane &
channels
o Regeneration
• Node formation
Hardy, Stephen, & Kleinman Ronald. (2007) Cirrhosis and

Chronic Liver Failure In: (Eds.) Suchy Frederick J., Sokol
Ronald J. & Balistreri William F. Liver Diseases in Children.
3rd. Ed., University Press, Cambridge
Cirrhosis
Injury→
formation
Cirrhosis collagen, &
basement
membrane
Regeneration,
Ischaemia & node
cell death formation →
↑pressure &
ischaemia

Cirrhosis
Portal Hypertension
Portal Hypertension
Reduced blood flow
through liver
Ascites
Splenomegaly
Collateral
circulation
Varices and
haemorrhage
(With thanks to Associate Professor Winita Hardikar
who supplied this slide)

Clinical Features of Liver Disease
o Malabsorption/diarrhoea o Coagulopathy
o ↓ Growth o Osteopaenia
o ↓ Development o Fluid & electrolyte
derangement
o Ascites o Hormone derangement
o Vomiting o Jaundice
o Gastro oesophageal reflux o Itching
Hardy, Stephen, & Kleinman Ronald,. (2007) Cirrhosis and Chronic Liver
Failure In : (Eds.) Suchy Frederick J., Sokol Ronald J. & Balistreri
William F. Liver Diseases in Children. 3rd. Ed., University Press,
Cambridge

Liver Disease – causes in children
Most causes are uncommon:
Chronic Acute
o Biliary atresia o Medications
o Alagille’s syndrome o Some Homeopathic
o A-1-antitrypsin deficiency remedies

o Wilson’s Disease o Poisons
o Autoimmune Hepatitis o Toxins
o others… o unknown - ?viral

Gastrointestinal Tract: obstructed
bile flow
 Absorption of fats
Absorption
Steatorrhea Weight loss  Growth
of vitamin ADEK

Gastrointestinal Tract: obstructed
bile flow
Management
o Formula with pre-digested fats
o Maximal calories
o Fat soluble vitamin supplements

Gastrointestinal Tract:
catabolic/anabolic
Glycolsis
Glucogenosis
Glucogeogenesis
Ketogemesis
Energy Weight Loss Growth Hypoglycaemia

Gastrointestinal Tract:
catabolic/anabolic
Management
o Monitoring of growth
o High calorie formula & diet
o Smaller & more frequent volumes
o N/G feeds (continuous)
o Control of ascites
o Conserve calories – keep well covered
o I/V Dextrose & BSL’s when fasting

Gastrointestinal Tract: portal
hypertension
o Gastropathy
o ↑ gastric secretion
o Varices (+/- Bleeding)
Varices - Gastroscopy
Hardy, Stephen, & Kleinman Ronald . (2007)Cirrhosis and Chronic Liver
Failure In: (Eds.) Suchy Frederick J., Sokol Ronald J. & Balistreri
Cambridge

Gastrointestinal Tract: portal
hypertension
Management
o Observation re haematemesis, malaena
o Careful placement of N/G tubes – lubricant ++, no
stilettes,
o Omeprazole
o Banding &/or Sclerotherapy
o Propanolol
o Portocaval shunts

Haematological System
o Splenomegaly
o Pancytopaenia
o ↓Clotting factors
o ↓Anti-coagulation
factors
o ↓Haemoglobin
o ↓WCC Hardy, Stephen, & Kleinman Ronald . (2007) Cirrhosis and Chronic
Liver Failure In: (Eds) Suchy Frederick J., Sokol Ronald J. & Balistreri
Cambridge

Haematological System
Management
o Observation for pallor, bruising, bleeding
o Careful management of I/V sites, or injections
o No contact sports re splenomegaly
o Vitamin K
o Iron supplements
o Doppler U/S re potential for thrombosed hepatic
vessels

Cardiovascular System &
Haemodynamics
Decreased renal
perfusion
o Peripheral
dilatation ADH secretion
o Collateral vessels Renin-
o Hyoalbuminaemia, angiotension,
(leak into aldosterone
peritoneum) activation
Cardens, Andres & Gines̀ Pere, (2005) Management of
complications of cirrhosis in patients awaiting liver
transplantation. Journal of Hepatology 42, S124-S133

Cardiovascular System &
Haemodynamics
Management
o Fluid balance, weight, girth, assessment of
ascites
o ↓Sodium diet
o Diuretics
o Albumin replacements

Renal System
o ↓Renal perfusion
  ADH
o Water retention &
hyponatraemia
Hepatorenal
Syndrome
Cardens, Andres & Gines̀ Pere, (2005) Management of
complications of cirrhosis in patients awaiting liver
transplantation. Journal of Hepatology 42, S124-S133

Renal System
Management
o Fluid balance, weight, girth,
o Fluid restriction
o Diuretics
o Albumin replacement
o Haemofiltration (Hepatorenal Syndrome)

Immune System
o Hypersplenism 
WCC
o Shunting → Kuffer
cell activity
o ↑Risk of infection
(Spontaneous
Bacterial
Peritonitis)
Hardy, Stephen, & Kleinman Ronald . (2007) Cirrhosis and Chronic Liver
Failure In: (Eds.) Suchy Frederick J., Sokol Ronald J. & Balistreri William F.
Liver Diseases in Children. 3rd. Ed., University Press, Cambridge

Immune System
Management
o Monitoring temperature
o Prompt attention to fevers
o Immunizations
o Antibiotic prophylaxis

Endocrine System
o ↓ Hormone activity: parathyroid,

mineral/gluco-corticosteroids, growth
& sex hormones etc
o ↓Growth & puberty
o ↓Vitamin D & bone mineralization
Hardy, Stephen, & Kleinman Ronald. (2007) Cirrhosis and Chronic Liver Failure In: (Eds.)
Suchy Frederick J., Sokol Ronald J. & Balistreri William F. (Eds.) Liver Diseases in
Children. 3rd. Ed. University Press, Cambridge

Endocrine System
Management
o Monitoring of growth & development
o Vitamin D replacement
o Careful handling to avoid fractures
o Maximal nutrition
o ?Post transplant hormone supplements

Respiratory System
o Ascites →
respiratory
excursion
o Muscle bulk →
respiratory
excursion
o Clubbing
Hepatopulmonary
o Arteriovenous syndrome (Resolves
shunts post transplant)
Hardy, Stephen, & Kleinman Ronald,. (2007) Cirrhosis and Chronic Liver
Failure In: (Eds.) Suchy Frederick J., Sokol Ronald J. & Balistreri William F.,
(Eds.)Liver Diseases in Children. 3rd. Ed University Press, Cambridge

Respiratory System
Management
o Monitoring of respiratory rate, effort &
oximetry
o Lung function tests
o Control of ascites
o Maximal nutrition
o Oxygen therapy (Hepatopulmonary

Syndrome)

Muscular/skeletal System
o ↓Muscle weakness
o Peripheral
neuropathy
o Tremors
o Osteopaenia
Hardy, Stephen, & Kleinman Ronald . (2007) Cirrhoisis and Chronic Liver Failure
In: (Eds.) Suchy Frederick J., Sokol Ronald J. & Balistreri William F. Liver Diseases
in Children. 3rd. Ed. University Press, Cambridge

Muscular/skeletal System
Management
o Observe for muscle weakness & tremors
o Observe for fractures
o Nutrition
o Vitamin, electrolytes & mineral

supplements

Neurological System
o Encephalopathy:
?↓Deamination of
aminoacids
? ↓urea &
ammonia
levels
Hardy, Stephen, & Kleinman Ronald, . (2007) Cirrhosis and Chronic Liver Failure
In: (Eds.) Suchy Frederick J., Sokol Ronald J. & Balistreri William F. Liver
Diseases in Children. 3rd. Ed., University Press, Cambridge

Neurological System
Management
o Monitor conscious state
o ↓Protein intake
o Lactulose
o Neomycin
o Shunt

Psychosocial: parents
o Grief o Loss of control

o Guilt o Disruption of life style
o Anger o Social isolation
o Helpless o Social stigma
o Anxiety & uncertainty re o Financial hardship
future o ↑Risk of marriage
o Concerns re managing disintegration
illness o Worry about impact on
o Lack of information siblings
Knafl Kathleen & Santacroce Sheila (2004) Chronic Conditions
and the Family In: (Eds.) Allen, Patricia Jackson & Verrsy
Judith A. PRIMARY CARE OF THE CHILD with a CHRONIC
CONDITION (4th Ed.) Mosby St. Louis

Psychosocial: management -
parents
o Partnership with parents
o Communication - open
o Education - verbal & printed
o Information
o Ready access to team
o Counselling
o Social worker – financial & other resources
o Introduction to other parents
o Parents support group

Psychosocial: infants & children
o Sadness o Social isolation
o Frustration o Developmental delay
o Anger o ↓Mastery
o Loss of control o ↓Confidence
o Separation (hospital) o ↓Self Esteem
o Fear of pain o ↑Dependence
o Concerns re body image o ↑Risk of emotional &
o Social stigmatization behavioural problems
o Disruption to life style
Knafl Kathleen & Santacroce Sheila (2004) Chronic Conditions

Angström-Brännström Charlotte, Norberg Astrid &
and the Family In: (Eds.) Allen Patricia Jackson & Vessey Judith
Jansson Lillian. August 2008. Narratives of Children
A. PRIMARY CARE OF THE CHILD with a CHRONIC CONDITION.
with Chronic Illness About Being Comforted. Journl of
4th Ed. Mosby St. Louis
Pediatric Nursing 23, (4) 310-316

Psychosocial: management -
infants & children
o Maximal parental participation in care
o Facilitation of communication
o Facilitation of choices
o Facilitation of routine
o Play Therapist - medical play & diversional
techniques
o Pain management team
o Counselling
o Music therapy
o Liaison with school

Summary: Principals of Nursing Care
o Monitoring vital signs, conscious state, growth, GI
losses
o Monitoring skin, limbs & abdominal distension
o Accurate fluid balance chart, weight & girth
o Optimization & conservation of calories
o I/V Glucose & monitoring BSL’s when fasting
o Careful insertion of N/G tubes
o Gentle handling & careful positioning
o Administration of medications/infusions
o Psychosocial support

Liver Disease
o Is a complex and miserable disease
o Requires meticulous medical & nursing care
o Impacts on all the systems
o Often results in liver transplantation


Liver Failure: Lyn Crellin

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Liver Failure: Lyn Crellin

Uploaded by

Copyright:

Available Formats

Liver Failure

Paediatric Liver Transplant Coordinator

Major functions of the liver

o Regulates blood clotting

o Produces & eliminates bile

o Neutralises and destroys toxins, drugs

o Detoxifies/eliminates – hormones, endotoxins etc

o Regenerates its own damaged tissue

o Stores glucose, iron, vitamins, minerals, blood

Guyton Arthur C. & Hall John E. (2006)

Inflammatory process Cirrhosis

Chronic Liver Disease 2008

Hardy, Stephen, & Kleinman Ronald. (2007) Cirrhosis and

Chronic Liver Disease 2008

Chronic Liver Disease 2008

Chronic Liver Disease 2008

o Alagille’s syndrome o Some Homeopathic

o A-1-antitrypsin deficiency remedies

o Autoimmune Hepatitis o Toxins

o others… o unknown - ?viral

Chronic Liver Disease 2008

Chronic Liver Disease 2008

Chronic Liver Disease 2008

Energy Weight Loss Growth Hypoglycaemia

Chronic Liver Disease 2008

o I/V Dextrose & BSL’s when fasting

Chronic Liver Disease 2008

Chronic Liver Disease 2008

Chronic Liver Disease 2008

Chronic Liver Disease 2008

Chronic Liver Disease 2008

Chronic Liver Disease 2008

Chronic Liver Disease 2008

Chronic Liver Disease 2008

o Haemofiltration (Hepatorenal Syndrome)

Chronic Liver Disease 2008

Chronic Liver Disease 2008

o Prompt attention to fevers

Chronic Liver Disease 2008

o ↓ Hormone activity: parathyroid,

Chronic Liver Disease 2008

o Careful handling to avoid fractures

o ?Post transplant hormone supplements

Chronic Liver Disease 2008

Chronic Liver Disease 2008

o Oxygen therapy (Hepatopulmonary

Chronic Liver Disease 2008

Chronic Liver Disease 2008

o Observe for fractures

o Vitamin, electrolytes & mineral

Chronic Liver Disease 2008

Chronic Liver Disease 2008

Chronic Liver Disease 2008

o Grief o Loss of control

Chronic Liver Disease 2008

Chronic Liver Disease 2008

Knafl Kathleen & Santacroce Sheila (2004) Chronic Conditions

Chronic Liver Disease 2008

Chronic Liver Disease 2008

Chronic Liver Disease 2008

o Is a complex and miserable disease

o Requires meticulous medical & nursing care