Care strategies for patients with severe drug-induced hepatitis

doi:10.4236/health.2011.34040

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Vol.3, No.4, 228-232 (2011) Health

doi:10.4236/health.2011.34040

Care strategies for patients with severe drug-induce d

hepatitis

Tingting Zhang, Yuan Liu, Qingqing Xu,Yaping Han*, Jun Li*

Department of Infectious Disease, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China;

*Corresponding Author: asian_peace@sina.com, prof.lijun@gmail.com; these authors contributed equally to this study.

Received 22 February 2011; revised 2 March 2011; accepted 14 March 2011.

ABSTRACT

Objective: The aim of this study is to analyse

the clinical characteristics of 32 patients with

severe drug-induced hepatitis, reinforce the

practice of unique nursing and holistic nursing,

improve the therapeutic effect, reduce the pa-

tients’ mortality, and increase their quality of life.

Methods: W e gi ve patients indiv idualized dietary

guidance, medication nursing, and psychologi-

cal care according to the characteristics of se-

vere hepatitis and its complications, using com-

prehensive medical treatment and combined

signs of Traditional Chinese Medicine. Results:

Overall, 22 (68.8%) out of 32 cases were im-

pro ved, 8 (25.0%) cases died, and 2 (6.2 %) cases

were discharged of free will. In addition, the av-

erage hospital stay was 28.75 days. Conclusion:

This study indicates that dietary guidance for

the patients with severe drug-induced hepatitis

varies with the individual. The result embodies

the concept of Traditional Chinese Med icine that

different treatment for the same disease and

different diet for the same disease. Special

nursing enriches the connotation of holistic

nursing. Both of them are vital for improving the

survival rate and promoting rehabilitation of

patient s with severe drug-induced hepatitis.

Keywords: Drug-Induce d L iv er In ju ry; S eve re

Hepatitis; Diet Nursing; Holistic Nur sing

1. INTRODUCTION

Liver is the most important metabolic organ. It is the

primary place of drug metabolism and the major target

organ of poison reaction by drug. In recent years, as the

drug type augments, patients with drug-induced liver

disease have increased steadily. Among these cases, ad-

verse drug reaction accounts for 0.6% of the hospitalized

patients and drug-induced liver failure accounts for 0.3%

of the total inpatient mortality [1 ].Therefore, we took the

positive control of multiple organ failure caused by se-

vere hepatitis according to the clinical features of the

disease and the specific circumstances of different pa-

tients. At the same time, through various changes of the

tongue in traditional Chinese medicine, an appropriate

diet care strategy was formulated to play a positive and

effective role in reducing complications and improving

the survival rate and quality of life.

2. METHODS

2.1. Clinical Data

2.1.1. General Information

From December 2002 to December 2008 our hospital

let in 32 cases of severe hepatitis complicated with

drug-induced liver injury, including 13 males and 19

females who se aver age ag e was 42, ag ing from 18 to 62.

All of them had medication history or history of expo-

sure to toxicants, including 29 (90.6%) cases of severe

chronic hepatitis and 3 (9.4%) cases of sub-acute severe

hepatitis. Clinical symptoms included extreme fatigue,

anorexia, dermatic and scleral icterus, dark urine, pro-

gressive jaundice, associated with fever, skin itching,

even oliguria, ascites or gastrointestinal bleeding, he-

patic encephalopathy, hepatorenal syndrome and distur-

bance of consciousness performance. Among 32 patients,

5 cases took anti-thyroid drugs for hyperthyroidism; 8

patients took medication for skin treatment; 3 cases were

treated with anti-tumor chemotherapy; 1 case took anti-

TB drugs; 3 cases took antibiotics; 2 cases took anti-

hypertensive; 6 patients took Chinese herbal medicine; 1

case once contacted with toxic chemicals complicated

with skin lesions and 3 patients were allergic to other

drugs accompanying skin lesions.

2.1.2 The Diagnostic Criteria

Classification and diagnosis of drug-induced hepatitis

T. T. Zhang et al. / Health 3 (2011) 2 28-232

229229

was based on Maria score criteria for drug-induced liver

injury [2], the diagn osis of severe hepatitis was based on

diagnostic criteria revised by the tenth National Confer-

ence on Viral Hepatitis and Liver in 2000 [3].

2.2. General Nursing

2.2.1. Close Observation of Condition

Close observation of patients’ awareness and con-

sciousness: For mild and moderate hepatic coma patients

who had disturbance of consciousness, personality and

behavioral disorders, we should increase inspection, pro-

mptly notify the doctor, give early diagnosis and imme-

diate treatments; patients with Dysphoria took a fixed-

bedside barriers ,and were cared by hand to prevent the

occurrence of self-harm or falling off bed; depth hepatic

coma patients were regularly checked with temperature,

pulse, respiration, blood pressure, urine output changes.

For patients with retention catheterization, their records

of color and volume of urine were kept, while we disin-

fected urethral orifice twice a day and regularly replaced

urine bag and catheter, in order to reduce the incidence

rate of secondary infection of urinary tract. Regularly

ob- serve the changes in peripheral circulation of limbs,

turn the body over and do passive exercise to limbs in

time to prevent the formation of pressure sores, and to

reduce the development of venous thrombosis and mus-

cle atrophy.

2.2.2. Fever Nursing

Some of the drug-induced liver injury patients com-

plicated with severe hepatitis would develop fever since

a large number of liver cells underwent rapid necrosis.

For the same patients with a temperature below 39˚C,

we gave physical cooling, and encouraged them to drink

warm water; for patients whose body temperature was

above 39˚C, we used antipyretic drugs as directed,

timely replaced with clean underwear to keep the skin

clean and dry, and prevent pathogenic microorganisms

break when patients caught cold because they were wet

with sweat.

2.2.3. Medication Nursing

For severe drug-induced hepatitis patients, especially

those had liver injury associated with immune patho-

genesis, their livers not only seriously damaged, while

might also be in an over stressing state. Therefore, on the

one hand, we should weigh the advantages and disad-

vantages before using drugs. During the process of car-

rying out doctor’s order, we should carefully check and

timely advice doctors to avoid the use of specific drugs

which could lead to liver injury, such as azithromycin,

methimazole, ketoconazole, etc. On the other hand, we

should observe patients’ response to treatment carefully

when we made bedside rounds, timely communicate with

patients and their families to tell them the role of drugs

used in order to obtain the trust and cooperation of pa-

tients, and prevent new liver injury caused by abuse or

improper use of drugs. The effective drugs for drug-

induced liver injury should improve symptoms of toxic

liver injury, accelerate bile acid transport, promote bili-

rubin metabolism and repair liver cells, such as reduced

glutathione, ademetionine, hepatocyte growth-promoting

facors, alprostadil, etc.

2.2.4. Artifici a l L iver Treatment Nursing

Patients with severe drug-induced liver injury gener-

ally had significantly decreased immune function. We

used artificial liver support system and exchanged pa-

tient plasma with the fresh plasma of healthy people.

Toxic substances above middle molecular mass could be

cleared from the body and coagulation factors, albumin

and other substances were added to improve the internal

environment quickly and promote the regeneration of

liver cells. However, during the course of treatment, or

within 2 hours after it, a small number of patients would

have allergy symptoms, such as chills, fever, perioral

numbness, skin itching and hives, or even a drop in blood

pressure, laryngeal edema. Some patients might have

bleeding and infection in the puncture site. Nurses must

do ideological work among patients and well prepare

operational technique before the artificial liver treatment.

For example, they informed patients and their families of

the purposes, principles, precautions before and after

treatment and possible side effects, and appropriately

allayed their anxiety and fear. The operator must have

Skillful puncture technique, master instrumentation,

strictly observe variety state intraoperative and postop-

erative, give timely treatments to symptoms, and ac-

cording to the serum bilirubin (TBIL) level, prothrombin

activity (PTA), cholinesterase (CHE), total cholesterol

(TC) and the results of the rapid changes in T lympho-

cyte subsets [4], adjust the treatment opportunely, com-

municate with patients and their families in time to

strengthen their idea of overcoming the disease.

2.2.5. Psychological Care

For drug-induced liver injury patients complicated

with severe hepatitis, disease progressed rapidly. Espe-

cially among young women with deep jaundice, they com-

monly had the consciousness of worry or even panic.

Therefore, we talked with patients on our own in itiative,

took care of them as family members, established feel-

ings of kindness and trust for nursing staff among pa-

tients, to keep patients in an active, optimistic, coopera-

tive state.

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230

2.3. Unique Care

2.3.1. The Principles of Diet Nursing

Diet nursing of severe hepatitis was important during

the medical treatment and rehabilitation process. Dietary

principle was not to aggravate the burden of liver, but to

make liver rejuvenesce. According to theory of Chinese

Traditional Medicine, for each indiviudal, we developed

a low-protein, low-fat, moderate-carbohydrate vitamin-

rich and low residue semifluid diet which was easy to

digest and can promote absorption. We also made a list

of appropriate food and food to be avoided, which fa-

cilitated memory and cooperation for patients’ families.

For sane patients, we usually encouraged them to eat

small, frequent meals and have a liquid or semi-liquid

diet, these patients needed approximately 1400-1600

kcal per day, which came from 20 g protein, 30 grams

fat, around 280 g carbohydrate. Patients with ascites or

renal dysfunction should control sodium and water in-

take. Gastrointestinal bleeding patients must fast 48-72

hours after the bleeding stopped and then they could be

given a small amount of low-temperature, no-residue

liquid diet which gradually transited to a semi-liquid diet.

Eat slowly and avoid hard, sticky, excitant food or a

residue diet. Hepatic coma or pre-hepatic coma patients

require a few more calories than common patients. We

should focus on the control of protein intake, appropri-

ately increase the amount of carbohydrates, use nasal

feeding liquid diet and intravenous nutrition if necessary.

Patients associated with glucose metabolism disorder

should change carbohydrate intake timely. A proper diet

not only facilitated normal bowel movements, but also

ensured daily nutrition supply to the body, promoted the

recovery from the illness and was of great significance

to reduce complicatio ns.

2.3.2. Recipe for Different Symptoms

Traditional Chinese Medicine is known as “medicine

that can be used both as food or medicine”, which means

that most of the traditional Chinese medicine derived

from food .It is said that the diet cures more than the

doctor and better wait on the cook than on the doctor.

The Tongue picture is one of the bases of treatment

based on symptom differentiation and signs to identify

etiology. Disease in the viscera and bowels is usually

reflected by the tongue picture. Changes of tongue coat

reflect the depth of pathogenic factors, while changes of

tongue substance often reflect the rise and decline of qi

and blood. Patients’ tongue coat changes more rapidly.

We should observe the changes of tongue coat daily and

adjust the recipe of patients appropriately.

2.3.2.1. Humid Heat Stagnation Type

Patients with red tongue substance and yellow greasy

tongue coat, bitter taste to the mouth and dry pharynx,

general fever , dark less urine ,uncomfortable defecation,

often use capillaris Capsella porridge, spaghetti with

yam and duck breast, snail soup, watermelon peel rind

bean soup, water chestnuts cane juice, Chin ese small iris

to clear away heat and promot diuresis.

2.3.2.2. Hepatosplenic Disorder, Incoordination

between the S pleen and Stomach Ty pe

Patients with pale tongue substance and thick greasy

tongue coat, chest and hypochondrium discomfort, no

appetite, abdominal distention after eating, disorders of

defecation, use coicis semen rice gruel, dried tangerine

peel yams duck breast porridge, lotus root Hawthorn

juice, shepherd’s purse, to disperse the depressed liver-

energy and regulate vital energy, invigorate spleen and

stomach.

2.3.2.3. Hepatic and Renal Yin Deficiency Type

Patients with red tongue substance, less saliva, less or

peeling tongue coat, dark and gloomy face, emaciation,

sultriness and dry mouth, gingival bleeding, urine defi-

ciency, use loach sp aghetti, sea cucumbers Capsella por-

ridge, capillaris Capsella yams juice, chrysanthemum

leaves to nourish liver and kidney; insomnia patients

with pulmonary tuberculosis and excessive phlegm, add

honeysuckle lily soup and so on to calm the nerves and

clean away the lung-heat.

2.3.2.4. Spleenic and Renal Yang Asthenia Type

Patients with pale tongue substance, smooth white

tongue coat, abdominal fullness and distention, abdomen

shaped like frogs, tired and afraid of cold, cold limbs and

edema, urine deficiency, watery stool, choose red dates

millet gruel, duck breast and shepherd’s purse porridge,

Chinese goosebeery and hawthorn juice, spinach, etc., to

warm spleen and kidney, disslove qi and promote diure-

sis.

2.3.2.5. Deficiency of Both Qi and Blood Type

Patients with deep red tongue substance and without

tongue coat, tongue curl and atrophy or dry and scorched,

looking gloomy, tired and fatigue, hepatosplenomegaly,

scaly skin, itching, most of whom were seriously sick,

use red bean rice gruel, shepherd’s purse porridge, lotus

root and hawthorn juice, to replenish the vital essence

and remove heat, supplement qi and activate blood cir-

culation.

2.3.3. The Role of Diet Nursing in the

Prevention of Complications

In clinical practice, for patients who took corticoster-

oid drugs for treatment, first, we evaluated the risk fac-

tors for bleeding, in addition to the preventive use of

T. T. Zhang et al. / Health 3 (2011) 2 28-232

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gastric mucosal protection drugs. Dietary regulation was

of significance in preventing the occurrence of stress

ulcer. We usually gave a small amount of high-quality

low-protein, high-carbohydrate, low-fat semi-liquid or

liquid diet to the patients; while for hepatic encephalo-

pathy or pre-hepatic encephalopathy patients with high

blood ammonia concentration, we not only strengthened

the observation of the consciousness and awareness of

patients, but also strictly limited the patients’ intake of

animal proteins. We determined the supply of plant pro-

teins according to clinical symptoms and ammonia lev-

els, which was not only one of the most important meas-

ures to control ammonia increase and to prevent hepatic

encephalopathy, but also the key point of prognosis for

patients who ha d alrea dy had hepati c coma.

3. RESULT

Among all the 32 patients who had been treated, 10

were treated with the artificial liver support system, 3

patients who got skin lesions were treated with corticos-

teroids, through a reason able diet nursing combined with

immunological regulation and comprehensive treatment.

No case had stress ulcer. As a result, in 22 (68.8%) cases

we had seen improvements after treatment, in 8 (25.0%)

cases the patients died, and in 2 (6.2%) cases the patients

abandoned the treatment and discharged of free will. The

average hospital days of stay were 28.75.

4. DISSCUSSION

Drug-induced liver injury is an iatrogenic disease

caused by drug or its metabolites. In the United States,

the most common medicine that can cause severe hepati-

tis is acetaminophen that belongs to antipyretic and an-

algesic class [5]. In China, anti-tuberculosis drugs and

Chinese herbal medicine are the most common cause

[6-9]. In recent years, the number of drug-induced liver

hepatitis cases increases rapidly [10] leading to the high

concern of society. Liver has a special anatomy location,

which undertakes internal blood filtation and external

detoxification of intestinal products [11], especially, oral

drugs which are absorbed via the gastrointestinal tract

carry out biotransformation and metabolism in liver.

Hence, drug concentration is significantly higher in liver

than in blood and other organs. Poor Daily diet not only

can impede rehabilitation but also has the potential of

increasing the degree of liver injury, causing hepatic

encephalopathy, upper gastrointestinal bleeding and other

serious complications. Therefore, appropriate diet can

provide proper nutrition to the body and promote the

repair and regeneration of liver cells.

Zhang zhongjing, the r enowned Chinese doctor of the

Eastern Han Dynasty, said in “Synopsis of Golden Cham-

ber”: “The taste of the food can help us get away from

diseases, which can also be harmful to the body, if it is

appropriate, it will benefit us, otherwise people will get

sick.” Chinese classic work “Huang Di Nei Jing” also

states: “Poison attacks evil, the five common cereals

support us, five kinds of fruits help us, five kinds of

animals benefit us, and five kinds of vegetables supple-

ment us, eat when the taste of food is appropriate to re-

plenish essence.” They indicated that improper food and

drug intake are closely related to the occurence of dis-

ease. There are more complications in patients with

drug-induced severe hepatitis, and especially gastroin-

testinal bleeding and hepatic encephalopathy are most

common. For these patients, the diet principle developed

by us was: combining patients’ tongue picture, select

food that was rich in nutrition and had a effect of

liver-protecting, lowering the transaminase, treating

jaundice, preventing hemorrhage and hepatic coma.

Moreover, the quantity of good quality protein which

produced low nitrogen was limited, in order to improve

hepatic steatosis, reduce nitrogen resources, and improve

the immune function of patients; To improve patients’

appetite and ensure heat supply to body for patients

whose jaundice had not resolved, it was recommended to

use a small amount of vegetable oil in cooking and avoid

fried food; consume carbohydrates in moderation to pro-

mote the use of amino acids in liver; and sufficient vita-

min supply to strengthen detoxification function of liver

and help liver cells repair. In the early stage of disease,

semi- fluid or soft rice which was easy to digest and nu-

tritious was selected. During comvalescent stage, a nor-

mal diet which was a less amount but had a good quality

was chosen to reduce the burden of the liver as the pri-

mary consideration. We made the use of the theory of

symptoms differentiation related to traditional Chinese

medicine, and developed personalized recipe for the pa-

tients with drug-induced severe hepatitis. A rational and

scientific diet not on ly could enhance the patients’ ab ility

to resist disease, but also was of great significance to

prevent gastrointestinal bleeding and hepatic encephalo-

pathy.

Our Traditional Chinese Medicine is extensive and

profound, in clinical practice. With the reduction of pa-

tient mortality and improvement of the life quality of

patients as a starting point, we cooperated with medical

workers, inspected personnel and multi-force. We took

Western medicine as the main treatment which was sup-

plemented by basic nursing, diet nursing, holistic nurs-

ing and psychological care, and reinforced various as-

pects to adjust immune function of patients, gradually

restore the balance between entrails, qi and blood, yin

and yang, so that the ineffective treatment rate of pa-

tients in this group was significantly lower than the 63.6%

T. T. Zhang et al. / Health 3 (2011) 2 28-232

232

reported at home [8]. This result indicated that the ther-

apy and care strategies using traditional Chinese medi-

cine together with western medicine and coordinating

exterior-interior relationship had a positive impact on the

outcome of patients with severe drug-induced hepatitis.

5. ACKNOWLEDGEMENTS

We thank Zhang Zhengfang Director for her warm guidance of die-

tary regulation for patients. This study was supported by the National

Natural Science Foundation grant (30,972,618), the funding for Ji-

angsu Province Key Laboratory (200707) and key medical personnel

in Infectious Diseases (RC2007049) and the funding for Guiding Re-

search Projects of Health Department of Jiangsu Province, China

(Z201001).

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