Page 190 - Critical Care Notes

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GI
■ Administer flumazenil (Romazicon), a benzodiazepine antagonist, if
necessary.
■ Use physical restraints as necessary. Provide reality orientation. Institute
measures for patient safety.
■ Administer medications with caution. Adjust dosage per liver function tests.
■ Provide a low-protein, low-sodium diet. Restrict fluids as necessary.
Consider enteral feeding or TPN if oral intake insufficient. Assess for hypo-
glycemia. Monitor serum albumin, electrolytes, and liver function tests.
IV glucose may minimize protein breakdown. Monitor glucose levels.
■ Prevent intravascular volume depletion through IV fluids, colloids, and
crystalloids. Avoid lactated Ringer’s solution.
■ Avoid hazards of immobility. Provide meticulous skin care.
■ Monitor ammonia levels (80–110 mcg/dL or 47–65 mcmol/L [SI units] is
normal).
■ Provide comfort measures and emotional support.
■ Prepare patient for TIPS to ↓ portal hypertension, prevent rebleeding from
varices, and ↓ formation of ascites or shunt surgery if indicated. Refer to
management under Esophageal Varices.
■ Prepare patient for liver transplantation if necessary. Calculate a MELD
score (Model for End-Stage Liver Disease) for transplant patient selection.
Refer to http://optn.transplant.hrsa.gov/resources/MeldPeldCalculator.
asp?index=98
Complications
■ Cerebral edema and increased ICP, and low cerebral perfusion pressure
■ Cardiac dysrhythmias and coagulopathy
■ Respiratory depression, acute respiratory failure, and respiratory arrest
■ Sepsis and circulatory failure
■ Acute renal failure
■ Hypoxemia, metabolic acidosis, and electrolyte imbalances
■ Hypoglycemia
■ GI bleeding
■ Hepatic failure may progress to hepatic encephalopathy → death.
Hepatic encephalopathy is divided into the following types:
■ Type A: Hepatic encephalopathy associated with acute liver failure
■ Type B: Hepatic encephalopathy caused by portosystemic shunting
without associated intrinsic liver disease
■ Type C: Hepatic encephalopathy associated with cirrhosis
■ The severity of hepatic encephalopathy is evaluated according to the
following grades:
■ Grade 1: Euphoria or anxiety, shortened attention span
■ Grade 2: Lethargy, apathy, subtle personality change, inappropriate
behavior, minimal disorientation to time or place
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