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very important to prevent indirect Bilirubin . from reaching to toxic level to brain which may lead to brain damage & kernicterus .
treatment include different modalities :-
Phototherapy
Exchange transfusion
Metalloporphyrins or Tin Mesoporphyrin
IV immunoglobuline ( IVIG )
Indirect hyperbilirubinemia. was reduced by use high intensity light in the visible spectrum & bilirubin absorb light maximally in the blue range from ( 420 – 470 nm ). phototherapy may decrease the need of exchange transfusion but not substitute it . It act by :-
photoisomerization which is conversion of toxic indirect ,unconjugated bilirubin (
4 Z, 15 Z ) to unconjugated isomer (4 Z , 15 E ) which is the product of reversible reaction that can be excreted in the bile with out need of conjucation .
Structural isomerisation which convert native bilirubin by irreversible reaction to lumirubin that is excreted in urin & bile with out conjucation .
Photoxidation convert it to small polar product which can excreted in urin
The therapeutic effect of phototherapy depend on :-wave length of light , distance between infant & light , amount of skin exposed , presence of hemolysis . Phototherapy need 6 – 12 hr to produce measurable effect to decrease total serum bilirubin ( TSB ).
Light source distance from infant is 45 cm & the infant should be naked all except for eye patch & baby should turn frequently (every 2 hr )for maximal exposure
fluid intake should increase by 10- 20 % due to over heating (cause dehydration )also baby should be weigh & temp check daily .
Baby with hemolysis or with TSB near toxic level TSB & PCV must be check every 4 – 8 hr while patient with lower level do TSB & PCV every 12 – 24 hr .
over heating & dehydration , so we increase 10 – 20 % of maintainance while he is on phototherapy .
loose stool & diarrhea .
erythematous macular rash & purpuric rash & with transient porphyraemia .
chilling .
eye injury & nasal closure from bandage (uncommo)
Bronze Baby Syndrome ( dark grayish brown ) especially in patient with direct or cholestatic jaundice , so should be avoid in patient with direct hyperbilirubinaemia ,
C/I in patient with porphyria
Exchange transfusion (ET) is widely accepted & used treatment of hyperbilirubinemia & prevention of bilirubin level from reach to degree that is toxic to brain , by ET there is
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removal of billirubin from plasma & also remove partially hemolysed & Ab coated RBC & unattached Ab & replaced by donar RBC which should lacking the sensitizing Ag.
The donar blood used should be fresh (< 7day old) irradiated whole blood with heparin or adenosin-citrat-phosphate dextrose as anticoagulant .
For Rh incompatibility blood shoud be obtained from Rh - ve donar whose cells are compatible with both mother & infant (usually we use type O – ve or infant ABO type used when mother has the same type .
In ABO incompatibility use type O Rh –ve or Rh compatible with infant & mother
(crossed match with mother & infant include indirect coomb's test ) .
ET carried out over 45 – 60 min. , alternate aspiration & infusion of 20 ml. Each time & sometimes 5 – 10 ml. Each time in sick patient or premature .
After ET , TSB decrease to ½ the pre exchange level immediately but rebound again 40 –
50 % within hours so we must do TSB at 4 – 8 hr. interval after exchange .
Repeated ET may be needed to prevent TSB level from reach maximum level to prevent
K. .
Hypoglycaemia ( before , during , after ) .
Hypoxia Acidosis ( during ET , check pH & paCO2
Transient bradycardia with or without hypocalcaemia
Hypocalaemia ( due to anticoagulant ) .
Cyanosis , Vasospasm .
Thrombosis .
Apnea with bradycardia
NEC ( rare ) . thrombocytopenia, volume overload, arrhythmias
Death 0.3 % .
Cholestasis .
Infection CMV, Hepatitis , HIV
Late anaemia ; haemolytic or hyporegenerative ; Rx by iron , erythropoitin , or blood transfusion .
Mild graft versus host reaction ( diarrhea , rash , hepatitis , eosinophilia
Inspissated bile syndrome ; rare jaundice persist for weeks or months
Portal vein thrombosis & portal hypertension .
New Rx reduce bilirubin and decrease both the need for phototherapy and length of hospital days; decrease serum B. by prevent conversion of heme-protein to biliverdin by enzymatic inhibition of heme-oxygenase
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A single dose on the 1st day of life may reduce the need for phototherapy. Such therapy may be beneficial when jaundice is anticipated, particularly in patients with ABO incompatibility or G6PD deficiency or when blood products are discouraged .
Side effect : Transient erythema when given with phototherapy
used adjunctive treatment for hyperbilirubinemia due to isoimmune hemolytic disease. when bilirubin approaching exchange levels despite maximal interventions including phototherapy. shown to reduce the need for exchange transfusion in both ABO and Rh hemolytic disease, presumably by reducing hemolysis.
Regardless of the cause, the goal of therapy is to prevent indirect bilirubin rising to neurotoxicity level ( kernicterus ) . Phototherapy and, if unsuccessful, exchange transfusion remain the primary treatment modalities used to keep the maximal total serum bilirubin below the pathologic levels
Because phototherapy may require 6–12 hr to have a measurable effect, it must be started at bilirubin levels below those indicated for exchange transfusion.
When identified, underlying medical causes of elevated bilirubin and physiologic factors that contribute to neuronal susceptibility should be treated (antibiotics for septicemia and correction of acidosis ) use a graph for Guidelines of intensive phototherapy & exchange transfusion level in hospitalized infants 35 or more weeks ’gestation . Which depend on
TSB level , age in hours and days , gestational age ,
Infant condition & presence of risk factors that increase risk of kernicterus at lower bilirubin level as
isoimmune hemolytic anemia , G6PD deficiency , asphyxia , intraventricular hemorrhage IVH .
lethargy , temperature instability sepsis , meningitis ,
acidosis , hypoalbuminemia (albumin < 3g / dl) Hypoglycemia .
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If TSB ( total serum bilirubin ) is not decreasing or is moving to level of exchange transfusion or the TSB/albumin ratio exceeds levels , consider exchange transfusion
If the TSB does not decrease or continues to rise in an infant who is receiving intensive phototherapy, this strongly suggests the presence of hemolysis.
Use total bilirubin , do not subtract direct (conjugated) bilirubin
In unusual situations in which the direct bilirubin level is 50% or more of the total bilirubin, there are no good data to provide guidance for therapy, and consultation with an expert in the field is recommended ,
Infants who receive phototherapy and have an elevated direct-reacting or conjugated bilirubin level (cholestatic jaundice) may inconsistently develop the bronze-baby syndrome ,
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if the TSB level is above the exchange level, or If TSB ≥25 mg/dL in (well , ≥ 38 wk gestation )or ≥20 mg/dL in a sick infant or infant <38 wk gestation, obtain a blood type and cross match, and request blood in case an exchange transfusion is necessary and put baby on intensive phototherapy repeat TSB measurement every 2–3 hr and consider exchange if the TSB remains above the levels indicated after intensive phototherapy for 6 hr.
B : A ( bilirubin \ albumin )ratios can be used together but not instead of TSB level as an additional factor in determining the need for exchange transfusion.
If TSB 20–25 mg/dL (342–428 μmol/L),put on phototherapy and repeat within 3–4 hr. If
TSB <20 mg/dL (342 μmol/L), repeat in 4–6 hr. If TSB continues to fall, repeat in 8–12 hr
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When TSB is <13–14 mg/dL (239 μmol/L), discontinue phototherapy measure TSB 24 hr after discharge to check for rebound
If any signs of Kernicterus ). are noted during evaluation or Rx as suggested any where in figure or at any level of B. , emergency ET must be performed .
In infants with isoimmune hemolytic disease and TSB level rising in spite of intensive phototherapy or within 2–3 mg/dL (34–51 μmol/L) of exchange level , administer intravenous immunoglobulin 0.5–1 g/kg over 2 hr and repeat in 12 hr if necessary
if not need immediate exchange transfusion at birth , we should put him after birth immediately on phototherapy & the decision to do exchange transfusion should be based on judgment that the infant has hight risk of rapid development of dangerous degree of
anemia & hyperB. .
cord blood TSB > 5 mg/dL , Hb <10mg suggest sever hemolysis but inconsistently predict the need of ET . Some physician consider Retic. Count > 15 % ,previouse K or erythroblastosis & prematurity to be additional factor support decision of ET
Attempt to predict the attainment of dangerous high level of serum bilirubin depending on observing
TSB > 6 mg/dL in the 1st 6hr.
or > 10 mg/dL in the 2nd 6hr. or TSB rising > 0.5 – 1 mg/dL/hr can be used in the management & doing ET but can be unreliable
the Rx is to keep ind. B. below maximal level ( table ) depend on body wt & if associated with complication or risk factor
So exchange transfusion done at these levels
BIRTHWEIGHT (g) UNCOMPLICATED COMPLICATED [*]
<1,000 12–13 10–12
1,000–1,250
1,251–1,499
1,500–1,999
12–14
14–16
16–20
10–12
12–14
15–17
2,000–2,500 20–22 18–20
Pototherapy is usually started at 50 - 70 % of the maximal indirect level .
If values exceed this level , if phototherapy is unsuccessful in reducing the maximal B. level , or if signs of K. are evident , ET is indicated
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Complications include perinatal asphyxia , acidosis , hypoxia , hypothermia , hypoalbuminaemia , meningitis , intraventricular haemorrhage , haemolysis , hypoglycaemia , or signs of K.
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