Case Study: Forbes Center for Rehabilitation & Healthcare (May 2015)

Admission Date: January 16, 2015
Admitted From: Allegheny General Hospital
Discharge Date: February 20, 2015
Discharged To: Home
Length of Stay: 45 Days
Reason for Stay: Liver Issues

Introduction: Patients with end stage liver disease can be challenging to manage in any healthcare setting. This case illustrates how CareRite Forbes took compassionate and effective care of a patient with complicated liver issues.

Vignette: Mrs. B was a 60 year old nurse with pulmonary hypertension, congestive heart failure and end stage liver disease. Nutrition is transported from the intestines to the liver by a large vein called the portal vein. The liver acts as a primary filter detoxifying poisons but also capturing and packaging raw nutrition. When the liver hardens due to cirrhosis (as was the case here) it blocks flow from the portal vein. Pressure in the portal vein builds up and the blood there tries to find a way back to the main circulation by veins in the stomach and esophagus. These veins then become very fragile and bleed. Mrs. B’s esophagus veins bled. Her doctors at the hospital used a tips procedure to connect the portal vein circulation with the normal (central) vein circulation in order to decompress the bleeding veins. Tips means that a catheter is placed in the main vein which is then used to poke a hole in the liver to the portal side, allowing flow that bypasses the liver itself. This in turn led to an unintended overflow into the main venous circulation and a condition we call pulmonary hypertension. The pulmonary hypertension was so severe that the tips procedure had to be reversed. Her course was complicated by respiratory failure requiring placement of a tracheostomy, dependence on a ventilator as well as a feeding tube from the nose to the stomach. Mrs. B came to Forbes Center with advanced liver failure, problems with her portal circulation and respiratory failure. Her liver failure manifested as fluid overload, loss of an ability to clot (bruising) as well as an inability to process the toxins of digestion (ammonia) resulting in extreme lethargy and confusion. Added to this was her tenuous dependence on tubes to provide respiratory support (ventilator machine connected to a trache tube in her throat) and a tube to supply nutrition and hydration (nasal – gastric tube.) Pulmonary hypertension made it difficult to balance fluids as too little hydration and the blood pressure would collapse and a bit more hydration and she would swell further and have greater difficulty breathing.

Course:
• Mrs. B was steadily weaned from the ventilator and then had her trache tube removed from her neck.

• While delirious Mrs. B pulled out her nasal feeding tube repeatedly, but nursing staff patiently replaced this important lifeline each time.

• Delirium was controlled by adjusting specific anti-ammonia medications (lactulose.) As lactulose restored Mrs. B’s mental faculties it allowed powerful antipsychotics to be gradually eliminated. This in turn improved her ability to participate in physical therapy and be restored to her old self. As her thinking improved so did swallowing and the feeding tube was removed.

• Severe anemia, inability to clot and fluid overloaded were carefully managed throughout.

Conclusion:
At the time of discharge Mrs. B had regained her personality, her mental focus and her physical strength. She was able to converse normally and also walk about, unassisted – completely free of breathing tube, ventilator and feeding tube. At no point did Mrs. B require rehospitalization. Complex nursing, medical, respiratory, speech and physical therapy management were done entirely at Forbes.