Hyperbilirubinemia

Neonatal Hyperbilirubinemia and management

1. HYPERBILIRUBINEMIA
Shini Cherian ,
NESD,
SFHD.

2. OBJECTIVES
Define Hyperbilirubinemia
State causes of hyperbilirubinemia.
 Discuss the pathophysiology of
hyperbilirubinemia.
Describe the most dangerous complication
of hyperbilirubinemia.
List the three elements of therapeutic
management.
Design plan of care for baby has
hyperbilirubinemia.

3. DEFINITION
Hyperbilirubinemia refers to an
excessive level of accumulated bilirubin
in the blood and is characterized by
jaundice, a yellowish discoloration of the
skin, sclera, mucous membranes and
nails.
Unconjugated bilirubin = Indirect bilirubin.
Conjugated bilirubin = Direct bilirubin.

4. INCIDENCE
Term : 60% of term neonates
Preterm : 80% of preterm neonates

5. Risk factors for jaundice
JAUNDICE
• J - jaundice within first 24 hrs. of life
• A - a sibling who was jaundiced as neonate
• U - unrecognized hemolysis
• N – non-optimal sucking/nursing
• D - deficiency of G6PD
• I - infection
• C – Cephalhematoma /bruising
• E - East Asian/North Indian

6. PATHOPHYSIOLOGY

10. MECHANISMS OF NEONATAL
JAUNDICE
1.Increased Bilirubin Load due to a high
hemoglobin concentration.
• The normal newborn infant
• Hemolysis
• Cephalhematoma or bruising , Polycythemia
2. Decreased Bilirubin Conjugation in the liver
• Decreased uridine glucuronyl transferase Activity
• Glucuronyl Transferase Deficiency Type 1 (Crigler
Najar Syndrome)
3. Defective Bilirubin Excretion

11. TYPES OF BILIRUBIN

12. Physiological jaundice
Characteristics
• Appears after 24 hours
• Maximum intensity by 4th-5th day in term
& 7th day in preterm
• Serum level less than 15 mg / dl
• Clinically not detectable after 14 days
• Disappears without any treatment

13. Pathological jaundice
Appears within 24 hours of age
• Increase of bilirubin > 5 mg / dl / day
• Serum bilirubin > 15 mg / dl
• Jaundice persisting after 14 days
• Stool clay / white colored and urine staining
clothes yellow
• Direct bilirubin> 2 mg / dl

16. Clinical assessment of
Jaundice

18. MANAGEMENT

26. Intensive Phototherapy

30. EXCHANGE BLOOD EXCHANGE BLOOD
TRANSFUSIONTRANSFUSION

32. In single volume exchange (in severe
neonatal anemia): A suggested rate is 15 aliquots over 1
hour that is, 4 minutes each cycle.
Aliqout volume(ml)= estimated blood volume x infant weight (kg)/
number of aliquots in 1 hour = 85ml x weight (kg) It is usually
5ml/kg
In double volume exchange: A suggested rate
is 30 aliquots over 2 hours that is, 4 minutes each cycle. This
is irrespective of whether the isovolumetric or push-pull
method is used.
Aliqout volume (ml) = estimated blood volume x 2 x infant weight
(kg)/ number of aliquots in 2 hours = 85ml x 2 x weight (kg) it is
usually 5ml/kg.

33. Rate of transfusion

35. Isovolumetric exchange- access is via
an umbilical venous catheter (blood in)
and an umbilical arterial catheter (blood
out).
Push pull method- using same catheter
that is the blood are pushed in pulled out
through the same umbilical venous
catheter.

36. ISOVOLUMETRIC METHODISOVOLUMETRIC METHOD

38. PUSH-PULL METHODPUSH-PULL METHOD

43. Check the patients chart for signed exchanged transfusion order
Check consent form signed by parents
Ensure exchange blood unit is available in the blood bank and have it brought to area just prior
to procedure.
Obtain received amount of blood from blood bank. Double check the blood pack with another
nurse to ensure correct identification.
Equipment for umbilical catheterization must be available including:
Clean equipment sterile equipment
Clean dressing trolley, blue sterile plastic sheet to place under sterile drape
IV infusion pump
Blood warmer
3.0 silk suture, sterile linen, cord tie, scalpel blade, tape measure
PPE like: masks protective goggles, sterile gown, two sets of sterile gloves, sterile green
drapes, sterile dressing, additional gauze swabs, assorted needles/ 5 ml syringes
 heparinized saline
 Unopened solutions for skin preparation(aqueous chlorhexidine)
 UVC 5 F infants 1000g and <28 weeks and 3.5 F infants <1000g or >28weeks
Prepare the infant for transfusion, after checking the identification band, keep NPO, Evacuate
gastric contents through a 8G=FG feeding tube and leave on free drainage; obtain baseline vital
signs and blood pressure.
Infants > 34weeks gestation are placed on servo mode but < 34weeks are managed in isollete.
Access for procedure: insertion of 5 FG umbilical catheter by physician to a level that allows free
flowing withdrawal of blood
Patient should be on continuous cardiac monitoring
Secure the infant’s upper and lower extremities as per restraint policy
Maintain the infant’s temperature with radiant warmer on servo control, take the infant’s
temperature at least hourly or as ordered

44. Standard precautions and aseptic technique should be
taken
The physician will connect the umbilical catheter to the
first adaptor on the 4-ways stopcock
Take a 20cc syringe from the tray, and attach to the
second adaptor on the way stopcock
Attach the blood administration set with extension tubing
to the third adaptor on the 4-way stopcock
Connect the remaining adaptor of the 4-way stopcock to
the waste blood container and secure properly below the
table level
Draw pre-exchange laboratory work including dextrose
stick
The nurse must observe the infant and record the amount
of blood out and amount of the blood in and time
Document heart rate, respiratory and blood pressure
every 5 minutes and inform physician of any changes in
the vital signs
Check blood glucose every 30minutes during the
procedure and every 30minutes x 2 after the blood
exchange.
Record on exchange transfusion record any medication
given during procedure

45. Blood Specimens
Initial or “First Out”.
 FBC & film.
 Blood Group, Direct Coomb's test.
 Urea and electrolytes, calcium, SBR, total and conjugated.
 Blood gas with PGL.
 Coagulations profile.
 Newborn screening test.
 Hold samples for other tests as indicated, e.g. G6PD deficiency, viral infection,
hereditary spherocytosis, metabolic studies.
Halfway Specimens
 SBR
 Blood gas with PGL
 FBC/Coagulation screen if warranted
End or “Last Out” specimens
 SBR, Urea & Electrolytes, calcium, magnesium, phosphate.
 FBC and Cross match for possible subsequent exchange.
 Coagulation studies.
 Blood gas with PGL
Post Exchange
Measure serum bilirubin within 2 hours

46. NICU Exchange Transfusion Chart
Date : Aliquots (circle one):
5 ml 10 ml 20 ml
Total
volume
to be
infused:

Vital signs
Cycle Time Volume out Total
out
Volume in Total in HR RE BP T SPO2 BSL
Sample
for lab.
Medications
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Total

47.  Infection
 Vascular complication
 Coagulopathies
 Electrolytes abnormalities
 Metabolic alkalosis
 Necrotizing Enterocolitis

48. QUESTIONSQUESTIONS
ANSWERSANSWERS
ANSWERSANSWERS
QUESTIONSQUESTIONS