Challenges of Liver Failure: an interactive discussion. Objectives

Transcription

1 Challenges of Liver Failure: an interactive discussion Zachary Erekson, M.D. Ann Broderick, M.D., MS Palliative Care Program, University of Iowa Hospitals and Clinics October 31 November 1, 2012 Objectives Describe the symptom burden of liver failure patients and optimal management. Define three treatment paths for liver failure patients. Outline how these treatment paths would be integrated into your practice. 1

2 Magnitude of end stage liver disease 5000 transplants/year 25,000 patients on the waiting list/year 2

3 What happens with end stage liver disease? Cirrhosis or scarring/fibrosis of the liver tissue Ascites Bleeding varices Peritonitis Hepatorenal syndrome Hepatocellular carcinoma 3

4 Symptom burden in liver disease Fluid disturbances Ascites Edema Infection Bacterial peritonitis Abdominal pain Immunnosuppression Bleeding/thrombosis Variceal bleeding Hemorrhoids Coagulopathy/Hypercoagulability Pruritis Nausea Encephalopathy When due to substance abuse, dramatic family dysfunction Case 1: 68 yo with Hep C cirrhosis Small hepatocellular carcinoma that has undergone embolic therapy. Goal is to be at home with his family. He needs taps every 2 3 weeks for comfort. Takes lactulose to reduce encephalopathy risk Has breakdown of his perianal skin due to the frequent stools. Hospice nurse stopped the lactulose as it was decreasing his quality of life. 4

5 Small group discussion points How does lactulose work? Are there alternatives? Did the nurse do the right thing? Case 2: End stage LD from biliary cirrhosis 67 yo African American woman Her family cares for her at home. They have an active primary doctor who thought that hospice might be a good idea to assist the family with all the care. The patient wants to get a transplant. Her MELD score is 32. 5

6 MELD score What is a MELD score? Uses serum albumin, creatinine, INR. Used now to determine ranking on the transplant list. In interpreting the MELD Score in hospitalized patients, the 3 month mortality is: 40 or more 71.3% mortality % mortality % mortality % mortality <9 1.9% mortality Can hospice and palliative care use this? EPERC Fast Facts MELD Score Predicted 6month survival % % % % 6

7 Other prognostic data Hepatorenal syndrome Type 1, rapid onset: 8 10 weeks Type 2, gradual: 6 months How can this patient be hospice appropriate? Seeking cure Will need repeated hospitalizations for every change in clinical status 7

8 Alcoholic hepatitis 48 yo presents to the ER with his brother. He is somnolent. His arms and legs show clear signs of muscle wasting. He has stigmata of liver disease. His abdomen is protuberant. His liver size is 20cm. Ultrasound of the liver shows no evidence of cirrhosis. His brother, clearly exhausted suggests hospice and you are the hospice staff who arrives. His Discriminant Function is 32. Discriminant Function for alcoholic hepatitis Calculated using PT and total bilirubin Predicts mortality in 28 days. Value over 32 predicts mortality of 35 45% in one month. Only valid in patients who have alcoholic hepatitis, and other causes of hepatitis should be ruled out. They might have stopped drinking 1 2 months earlier. May direct treatment (pentoxyphylline). 8

9 What is the correct response for the hospice medical team? Is he hospice appropriate? Three care paths upon discharge from hospital or clinic Patient who is still a transplant candidate or seeking life extension. Not a transplant candidate but mentation is still important, and/ or wants to live as long as possible Comfort measures only in the patient who can/not still swallow 9

10 Transplant or high intervention Discharge from hospital/clinic for patient who is hoping to maintain sobriety for 6 months, who is not sick enough for transplant yet or who is already on the transplant list with: Rifaximin ($$$) or Lactulose to have mental clarity/produce 2 stools a day Cipro/SBP prophylaxis if has had documented subacute bacterial peritonitis Diuretics Beta blockers if varices. Xenaderm or other protection for perianal region Itching: ondansetron, naloxone trial followed by oral naltrexone. AVOID antihistamines which sedate. Cholestatic pruritis is usually not histaminic. No benzodiazepines or opiates unless there is a change in the goals of care. Pain med: none, or acetaminophen 1gm BID if not actively drinking (last 2 months) Renal impairment: midodrine, octreotide Paracentesis as needed for symptoms not just for accumulation of fluid. Nursing instructions: Monitor urine output Check abdomen daily for tenderness Ambulate Monitor for asterixis, and monitor mental status Nutrition: Sodium restriction to less than 2 gms; Protein 1.5g/kg body weight No fluid restriction unless hyponatremic Appointments with liver specialist/doc every month. Repeated admissions will occur. Live as long as possible, no cure Same as above, including the confirmation of transplant status No medications for renal impairment Appointments with physician in the community/hospice physician every month for consideration of high volume paracentesis for comfort, with albumin infusion. Once the patient can no longer come into the hospital for taps, a pigtail catheter for low volume taps can be considered. (Requires a goals of care change to not returning to hospital). 10

11 Comfort measures only in the patient who can still swallow Rifaximin or lactulose Cipro Beta blockers Xenaderm Opiates Haldol or benzodiazepine trials if needed for restlessness. No nursing monitoring except for comfort and absence of agitation. Comfort measures for the patient who cannot swallow Xenaderm Opiates Medication for agitation 11

12 Which care plans would be achievable at your hospice? Proposal for a hospice position statement on end stage liver disease 12

13 Symptom/Syndrome management Ascites Stop alcohol use. Consider Baclofen. Sodium restriction (2g per day) Spironolactone and Lasix Therapeutic paracentesis TIPS? Catheter Symptom/Syndrome management SBP Prophylaxis recommended after first episode. Ciprofloxacin 750 mg PO weekly Norfloxacin 400 mg PO daily Bactrim DS 1 tab PO daily If GI bleed Ceftriaxone 1g IV once, then norfloxacin 400 mg PO BID for one week. May consider primary prophylaxis if ascitic fluid protein <1.5 g/dl and one of the following: Serum creatinine >1.2 BUN >25 Serum sodium <130 Child Pugh score >9 with bilirubin >3 13

14 TIPS Transjugular intrahepatic portosystemic shunt Indications are variceal bleeding and diureticresistant ascites May worsen hepatic encephalopathy Variable effects on hepatorenal syndrome, hepatopulmonary syndrome not indicated Symptom/Syndrome management Hepatic encephalopathy Treat hypokalemia (important but often overlooked) Lactulose titrated to 2 3 soft stools per day Rifaximin 550 mg PO BID Variceal bleeding Non selective beta blocker (such as propranolol) Band ligation TIPS 14

15 Symptom/Syndrome management Hepatorenal syndrome Midodrine, octreotide, and albumin Hepatopulmonary syndrome No specific medical treatment Patient positioning and supplemental oxygen may improve symptoms Pruritis Opioid antagonists Ondansetron Objectives how did we do? Describe the symptom burden of liver failure patients and optimal management. Define three treatment paths for liver failure patients. Outline how these treatment paths would be integrated into your practice. 15

16 Questions? For questions later, you may always call the University of Iowa Hospitals and Clinics at Ask for: Liver Fellow on call Liver attending on call Palliative care attending on call 16

17 Liver failure and hospice Drs. Zac Erekson and Ann Broderick University of Iowa Proposed admission to hospice Communicate with primary liver physician for transplant status and primary outpatient physician Discharge from hospital/clinic for patient who is hoping to maintain sobriety for 6 months, who is not sick enough for transplant yet or who is already on the transplant list with: Rifaximin ($$$) or Lactulose to have mental clarity/produce 2 stools a day Cipro/SBP prophylaxis if has had documented subacute bacterial peritonitis Diuretics Beta blockers if varices. Xenaderm or other protection for perianal region Itching: ondansetron, naloxone trial followed by oral naltrexone. AVOID antihistamines which sedate. Cholestatic pruritis is usually not histaminic. No benzodiazepines or opiates unless there is a change in the goals of care. Pain med: none, or acetaminophen 1gm BID if not actively drinking (last 2 months) Renal impairment: midodrine, octreotide Taps as needed for symptoms not just for accumulation of fluid. Nursing instructions: Monitor urine output Check abdomen daily for tenderness Ambulate Asterixis Nutrition: Sodium restriction to less than 2 gms; Protein 1.5g/kg body weight No fluid restriction unless hyponatremic Appointments with liver specialist/doc every month. Repeated admissions will occur. Discharge for the patient who will never get on the transplant list due to absence of social support, or inability to stop drinking but for whom mentation is still important, or who wants to live as long as possible Same as above, including the confirmation of transplant status No medications for renal impairment Appointments with physician in the community/hospice physician every month for consideration of high volume taps for comfort with albumin infusion.

18 Once the patient can no longer come into the hospital for taps, a pigtail catheter for low volume taps can be considered. (Requires a goals of care change to comfort only). Comfort measures only in the patient who can still swallow Rifaximin or lactulose Cipro Beta blockers Xenaderm Opiates: hydromorphone preferred in renal failure Haldol or benzodiazepine trials if needed for restlessness. No nursing monitoring except for comfort and absence of agitation. Comfort measures for the patient who cannot swallow Xenaderm Opiates Medication for agitation