What should be included in an in-hospital care plan for patients with cirrhosis?

Comprehensive In-Hospital Care Plan for Cirrhosis Patients

A comprehensive in-hospital care plan for cirrhosis patients should include early palliative care consultation, expert hepatology consultation, management of complications, and ongoing assessment of organ failure to optimize morbidity and mortality outcomes. 1

Initial Assessment and Monitoring

• Evaluate severity of cirrhosis using validated scoring systems such as MELD score, Child-Pugh score, and CLIF-SOFA score to guide management decisions and predict mortality 1
• Assess for number and severity of organ failures, as this is a crucial prognostic factor with 28-day mortality ranging from 4.7% in patients without organ failure to 76.7% in patients with ACLF grade 3 1
• Monitor evolution of SOFA score during ICU stay, as this is a critical prognostic indicator with scores >10 predictive of mortality in 93% of cases 1
• Perform reassessment of organ failure at day 3 and day 7, as this predicts outcomes better than initial assessment 1

Expert Consultation Requirements

• Obtain hepatology expert consultation immediately upon admission if the patient is already on a liver transplantation waiting list 1
• Seek expert hepatology advice soon after ICU admission to determine appropriate intensity of care based on number of organ failures and their progression 1
• Consult experts when considering liver support techniques 1
• Arrange hepatology follow-up at discharge to organize ongoing management and evaluate potential for liver transplantation 1

Palliative Care Integration

• Initiate palliative care consultation for all patients with cirrhosis at hospital admission, especially those with ACLF or requiring ICU admission, to improve quality of life and reduce readmissions 1
• Conduct goals of care discussions at key sentinel events including hospital admission, ICU admission, before initiating life-supporting therapies, and after determination of transplant eligibility 1
• Assess for symptoms across physical, psychological, social, and spiritual domains related to liver disease 1
• Screen for caregiver support needs, particularly for patients with decompensated disease 1
• Evaluate for hospice referral for patients with comfort-oriented goals and prognosis of 6 months or less 1

Management of Complications

• Assess for and manage thromboembolism risk with appropriate prophylaxis, considering individual bleeding risk 1
• Consider intermittent pneumatic compression devices for patients at high risk of both thromboembolism and bleeding 1
• Monitor for and aggressively treat infections, as they are associated with high mortality in cirrhosis patients 1, 2
• Implement protocols for management of hepatic encephalopathy, including identification and treatment of precipitating factors 3
• Use lactulose as first-line treatment for acute overt hepatic encephalopathy, and consider lactulose plus rifaximin for prevention of recurrence 3
• Manage ascites with appropriate diuresis, salt restriction, and antibiotic prophylaxis for spontaneous bacterial peritonitis when indicated 4

Transplant Considerations

• Do not exclude patients from ICU admission solely based on their cirrhotic condition 1
• Recognize that acute decompensation does not contraindicate liver transplantation and may actually prioritize the patient on the transplant list 1
• Understand that liver transplantation listing and palliative care services are not mutually exclusive 1

Nursing Care and Multidisciplinary Approach

• Incorporate nurses with specific knowledge of liver diseases into the multidisciplinary team managing cirrhosis patients 5
• Implement rigorous monitoring protocols both in and outside the hospital 5
• Provide medical education to patients and caregivers about disease management 5

Discharge Planning

• Arrange hepatology follow-up to organize ongoing management and evaluate potential for liver transplantation 1
• Schedule follow-up clinical assessment with laboratory tests and calculation of Child-Pugh and MELD scores every 6 months 6
• Establish clear communication between hospital and primary care providers to ensure continuity of care 5

By implementing this comprehensive care plan, healthcare providers can optimize outcomes for hospitalized cirrhosis patients while addressing both medical management and quality of life concerns.