bilary drains...

[Fairlythere, ASN, RN]

Sorry if that is mispelled. I had a patient (Im a new RN) a couple times last week who has cirhhosis, jaundice,a very distendended abdomen and a bilary drain. He has been sober for approx. four weeks and prior to hospitalization was homeless. He was usually oriented but cannot hardly stand up and is a two person assist to bedside commode. He has intermittent diarrhea also.

Anyway, first of all his drain, it has a stopcock on it and I learned to flush it q shift, but around the drain it "leaks". I have to change the gauze and abdomnial pad over it three or four times a shift. No one seems to be able to explain why this is. The drain is intact and draining bile colored fluid regularly.

Second, he is obviously very sick and has been there about two weeks, however recently he has been stumbling on his words and has to be reoriented to day and night, thinks its dinner time at 11, etc. He is easily reoriented though and even expressed frustration about his inability to remember words.

I reported the change of course, but am inexperienced. Curious what your thoughts are. Thanks...... A Newbe

[twinmommy+2, ADN, BSN, MSN]

I am also inexperienced, but have had a few cirrhosis patients since starting work. I wonder if its acities leaking from around the biliary drain? One man we had was so sick and had so much acities we had to place a urostomy bag around the site they used to drain it the day before. That actually worked pretty good as he was soaked with it constantly.

[twinmommy+2, ADN, BSN, MSN]

I forgot to add that the confusion is from accumulating ammonia levels that are affecting his brain coming from his bad liver. That can be expected.

[dorimar, BSN, RN]

His confusion is likely coming from elevated ammonia levels due to his hepatic failure. Lacutlose is commonly given to help rid the ammonia from the GI tract. Also certain oral anitbiotics help with this as well ( i think neomycin and an oral derivitve of rifampin) to irradicate the normal intestinal flora that produce ammonia (i believe). Also, you don't want to let his potassium get low either, because when the kidneys try to hang onto a potassium molecule, they also hang on to an ammoina molecule (or something llike that, if memory serves).

As to why the drain is leaking, my first thought would be that it wasn't patent, but you have stated that it was. It may just be that the insertion area has gotten larger than the drain, thereby allowing leakage around the drain.

You will also have to watch out for his coags and bleeding potential. It is highly likely that his PT INR is elevated, he may be thrombocytopeinc as well. For the coagulapathy we often give VIT K and FFP. Also with cirrhosis, patients usually have portal hypertension (elevated pressure in the portal venous system causing a back up) which can lead to esophogeal and gastric varicies which can rupture and bleed (many times fatal) especially with the common coagulapthaties present in liver disease. In the emergent instance of varicies bleeding, a TIPS procedure may done. This involves interventional radiology percutaneously (via IJ) placing a stent from the hepatic vein through the parenchyma of the liver to the portal vein creating a shunt thereby lowering the portal pressures and alleviating the gradiant of pressures between the RA and portal vein. also embolization for the bleeding varicies can be don at this time as well.