Arnol Nylcy1,*, Parimala2
1Staff Nurse, Kauvery Hospital, Chennai, Tamilnadu, India
2Clinical Instructor, Kauvery Hospital, Chennai, Tamilnadu, India.
*Correspondence: +91 94435 68280; santhi.j@kauveryhospital.com
Acute liver failure: A case report
Abstract
Acute liver failure (ALF) is a severe consequence of sudden hepatic injury, and has a poor prognosis. It can evolve over days or weeks. Some of the important etiological factors for ALF are alcoholism, paracetamol toxicity, viral hepatitis, Non-alcoholic steato-hepatitis, poisoning (rat killer, OPC, poisonous mushroom), and drug-induced liver injury. Damage to the liver cells produce altered mental status, significant elevation of liver enzymes and disturbed coagulation process. It requires early recognition and effective immediate management. Liver transplantation should be considered as a surgical management for acute liver failure thereby avoiding a life-threatening crisis.
Keywords: Acute Liver Failure, Liver Transplantation, Therapeutic Plasma Exchange
Background
According to a report published in Clinical and Experimental Hepatology rodenticide poisoning is very common in south India. The report stated that 40% of patients with rodenticide poisoning develop hepatotoxicity and acute liver failure; 76 & 24% respectively were from rural and urban areas; 62% were female and male 38%. Therapeutic Plasma Exchange(TPE) procedure and transplantation provide good survival benefits for patient with acute liver failure.
Case Presentation
A 21-year-old female was admitted to a government hospital in a town, with history of Ratol poisoning. Stomach wash was given immediately and patient referred to a General Hospital for further management. Laboratory investigations showed elevated bilirubin, SGOT and SGPT levels. The patient was transferred to another hospital for Therapeutic Plasma Exchange procedure; four cycles of TPE were done. The patient had persistent elevation of liver enzymes levels and PT & INR values.
Patient was diagnosed with Acute Liver Injury, recommended for liver transplantation and referred to Kauvery Hospital. On arrival, she was tachypnic. X-ray report showed consolidation of left lung. Patient was shifted to ICU and non-invasive ventilation support given. One cycle of TPE was started due to the increased INR and fibrinogen level. Patient’s status and need for liver transplantation were explained to family members, and were counselled.
Patient’s mother was willing for liver donation. Basic investigations that are required for donor were done. Consent was obtained from donor and the procedure was started. Patient was electively intubated and mechanical ventilation support given. Liver transplantation procedure was done successfully.
On clinical assessment
| Temperature | Pulse | Respiration | Blood pressure | SPO2 |
| 98.6 F | 98/min | 28/min | 120/80mmHg | 100% |
On physical examination patient was conscious, tachypnic with irritable behavior.
Management
The patient was initially treated with plasma exchange procedure and non-invasive ventilation support. Post- transplantation patient was on sedation.
She was extubated on POD-2, connected to NIV and gradually weaned off. O2 saturation was maintained with high flow nasal cannula. The patient received immunosuppressive agents, antibiotics (Inj.Meropenem 1GM), anti-fungal and anti-viral agents and correction of hypokalemia.
On POD-3 Ryle’s tube feeding was started and femoral line was removed.
On POD-4 lab reports showed hypokalemia and low Hb level. One unit of PRBC was transfused. Potassium correction was given. Liver enzymes values were in the normal range. ECHO showed normal features and liver Doppler study showed gradual improvement in liver function.
POD-5 oral diet was started and on P0D-6 all the lines and tubing were removed.
At the time of discharge patient was conscious, oriented and hemodynamically stable.
Drug chart
| S.No | Drug name | Dosage | Frequency | Route |
| 1 | T.Prograf | 1.5mg | BD | Oral |
| 2 | T.Wysolone | 40mg | OD | Oral |
| 3 | T.Mofetyl | 360mg | BD | Oral |
| 4 | T.Flucanazole | 200mg | BD | Oral |
| 5 | T.Zovirax | 400mg | BD | Oral |
Nursing care
Pre-Op
- On admission, she had breathing difficulty; NIV support was given and maintained patent airway. Patient respiratory status was stable.
Post- Op
- Post- operatively patient was on mechanical ventilator support.
- Suctioning was given every second hourly.
- Staff nurses maintained care bundles.
- Patient was on inotropic support and vitals were monitored hourly. Patient was hemodynamically stable.
- Intake / output chart was maintained accurately.
- Nutritional support was enhanced with soft solid diet.
- Aseptic precautions were followed during patient handling and dressing procedure.
- Calm and quiet environment was given to promote sleep. Psychological support was given.
Discussion
Rodenticide poison can cause extreme toxicity, lead to increased production of free radicals and affect multiple organs. Rodenticide yellow phosphorus is a commonly consumed compound and is associated with high mortality rate. Rural population are higher risk for rodenticide poisoning and the age group is usually between 18-30 years. Plasma exchange is a therapeutic treatment for ALF. Careful monitoring and recording of liver, kidney function and coagulation profile are required. Plasmapheresis and Liver transplantation show significant improvement in patients with acute liver failure.
Conclusion
Rodenticide ingestion is a very common cause of acute liver failure. Patients are generally in a younger age group between 18-45. One third of patients have poor prognosis and outcome in Tamil Nadu. Reducing mortality rate from poisoning will require early initiation of medical management and transplantation.
References
- Isackson B, et al. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022.
- Govindarajan R, et al. Rodenticide ingestion is an important cause of acute hepatotoxicity in Tamil Nadu, southernIndia. Indian J Gastroenterol 2021;40(4):373-9.
- Rotundo L, et al. Liver injury induced by paracetamol and challenges associated with intentional and unintentional use. World J Hepatol 2020;12(4):125-36.
Ms. Arnol Nylcy
Staff Nurse