HYPERBILIRUBINEMIA.pptx in children and newborn

it is very useful for nursing students

1. HYPERBILIRUBINEMIA

2. D E FIN I T I ON 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.

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

4. 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

5. PATHOPHYSIOLOGY

6. 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

7. TYPES OF BILIRUBIN

8. 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

9. 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

10. C l inica l asse s smen t o f Jaundice

11. MANAGEMENT

12. Intensive Phototherapy

13. EXCHANGE BLOOD TRANSFUSION

14. In single volume exchange ( in severe neonatal anemia): A suggested rate is 15 aliquots over 1 hou r t h a t i s , 4 m i nu t e s e a c h c y c l e . Aliqout volume(ml)= estimatedbloodvolume x infant weight (kg)/ number of aliquots in 1hour = 85ml x weight (kg) It is usua l y 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) = estimatedbloodvolume x 2x infant weight (kg)/number of aliquots in 2hours = 85ml x 2x weight (kg) it is usua l y5ml/kg.

15. Rate of transfusion

16. 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.

17. ISOVOLUMETRIC METHOD

18. PUSH-PULL METHOD

19. ➢ ➢ ➢ ➢ ➢ C h e c k t h e p a ti e n t s c h a r t f o r s i g n e d e x c h a n g e d t r a n s f u s i o n o r d e r C h e c k c o n s e n t f o r m s i g n e d b y p a r e n t s 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 tro l ey, 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 PPElike: 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 iso l ete. Access for procedure: insertion of 5 FG umbilical catheter by physician to a level that a l ows 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

20. Standard precautions and aseptic technique should be taken T h e p h y s i c i a n w i l c o nn e c t t h e u m b i l i c a l c a t h e t e r t o t h e f i r s t a d a p t o r o n t h e 4 - w a y s s t o p c o c k T a k e a 2 c c s y r i n g e f r o m t h e t r a y , a n d a t t a c h t o t h e s e c o n d a d a p t o r o n t h e w a y s t o p c o c k Attach the blood administration set with extension tubing t o t h e t h i r d a d a p t o r o n t h e 4 - w a y s t o p c o c k Connect the remaining adaptor of the 4-way stopcock to t h e w a s t e b l oo d c o n t a i n e r a n d s e c u r e p r o p e r l y b e l o w t h e 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

21. 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

22. NICU Exchange Transfusion Chart Date : Aliquots (circle one): 5 ml 10 ml 20 ml Total volume to be in fu s e d : Vital signs Cycle Time Volume out T o t a l out Volume in Total in HR RE BP T SPO2 BSL S a m p l e for lab. Medications 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Total

23. Infection V a s c u l a r c o m p l i c a t i o n Coagulopathies Electrolytes abnormalities Metabolic alkalosis Necrotizing Enterocolitis

24. Q U E S T IO N S A NSW E R S A N S W E R S Q U E S T IO N S