Biliblanket: Tratamento para icterícia neonatal

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NURSING
PRACTICE &
SKILL
Authors
Sara Richards, MSN, RN
Cinahl Information Systems, Glendale, CA
Carita Caple, RN, BSN, MSHS
Cinahl Information Systems, Glendale, CA
Reviewers
Dawn Stone, PhD(c), RN, ANP, COHN-S
Amy Hurst, RN, MSN
Cinahl Information Systems, Glendale, CA
Nursing Practice Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA
September 16, 2016
Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2017, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
Biliblanket: Using
What is a Biliblanket?
› Physiologic jaundice (i.e., a yellow coloration of the skin and sclera caused by the
accumulation of unconjugated bilirubin) is common in newborns, occurring in almost
two-thirds of infants due to their limited ability to completely metabolize and excrete
bilirubin (i.e., a by-product of the breakdown of the heme molecule found in RBCs).
Pathologic jaundice, or neonatal hyperbilirubinemia (NHB) occurs when there is an
increase in the concentration of unconjugated bilirubin in the circulating blood of the
newborn,and can lead to complications ranging from mild to life-threatening(e.g.,
bilirubin encephalopathy); early intervention is necessary to prevent complications. The
primary treatment for NHB is phototherapy, a non-invasivetreatment which typically uses
fluorescent light to decrease levels of unconjugated bilirubin (for more information, see
What You Need to Know Before Using a Biliblanket, below)
›
› What: A biliblanket is a portable fiberoptic phototherapy device used in the treatment
of NHB; it is an effective, easy-to-usealternative to conventional phototherapy using
overhead fluorescent lights (Figure 1). A biliblanket is a light-permeable, woven
fiberoptic pad that emits high-intensity light with no ultraviolet (UV) or infrared
irradiation. While Biliblanket is a trademarked name for a specific type of phototherapy
device, the term biliblanket is commonly used in medical settings to refer to a range of
similar phototherapy devices
› How: A biliblanket system is comprised of a fiberoptic pad, a connector cable, and a
light-generating box. The light-generating box is placed on a flat, non-absorbent surface
and connected by the connector cable to the fiberoptic pad. The pad is covered with a
disposable pad and the light-emitting side of the pad placed on the infant’s torso (front
or back), such that as much of the newborn’s skin as possible comes into contact with the
pad ; clothing can be worn over the pad, if desired, or the infant can be covered with a
blanket
›
›
› Where: Monitoring for NHB and use of a biliblanket may be performed in a well-baby
nursery setting, a neonatal intensive care (NICU) setting, or the home environment
› Who: In the inpatient setting, licensed nurses are responsible for applying biliblankets
and for patient monitoring. Parents/caregivers can also be taught to use a biliblanket in
the home setting; however, frequent clinic visits are necessary to monitor the status of a
newborn being treated with a biliblanket in the home
What is the Desired Outcome of Using a Biliblanket?
› The desired outcome of using a biliblanket is to lower the newborn’s total serum bilirubin
(TSB) level to the normal range and to reduce the likelihood that the newborn will
develop complications of NHB (e.g., bilirubin encephalopathy)
Why Is Using a Biliblanket Important?
› Using a biliblanket is an important method of treating NHP and preventing potential
complications of NHB, particularly neurotoxicity
• Severe NHB can lead to bilirubin encephalopathy (also called kernicterus). Kernicterus is a rare neurological disorder
affecting the basal ganglia and brainstem nuclei. Acutely, the newborn is severely jaundiced, lethargic and hypotonic, with
poor feeding. If uncorrected, the infant develops hypertonia, manifested by backward arching of the neck (i.e., retrocollis)
and trunk (i.e., opisthotonus), and may develop a fever and a high-pitched cry. Surviving infants usually develop a severe
form of athetoid cerebral palsy with upward gaze and twisting movements of the forelimbs; mental retardation, deafness,
and spastic quadriplegia may also result
› As compared to other interventions, use of a biliblanket is a relatively low-cost, non-invasive method for treating NHB that
family/caregivers can be taught to do on an outpatient basis
Facts and Figures
› The American Academy of Pediatrics (AAP) recommends using nurse-initiatedclinical pathways to guide treatment of NHB.
After implementing such a clinical pathway, emergency department physicians reported a reduction in time to phototherapy
treatment, time to TSB measurement, and overall length of emergency department stay (Wolff et al., 2012)
› Cochrane reviewers who performed a meta-analysis of randomized controlled trials determined that the use of prophylactic
phototherapy in preterm and low birth weight infants helps to maintain a lower TSB concentration and may lower rates of
exchange transfusion and neurodevelopmental impairment. However the authors cautioned that more research was needed to
determine the efficacy and safety of prophylactic phototherapy on long-termneurodevelopment (Okwundu et al., 2012)
What You Need to Know Before Using a Biliblanket
› Prior to using a biliblanket as a method to treat NHB, the nurse clinician should be familiar with the following:
• Pathophysiology of NHB and factors which increase risk for severe NHB
–Bilirubin is a by-product of RBC breakdown; bilirubin is typically bound to albumin (i.e., conjugated [or direct] bilirubin)
and excreted by the liver. NHB develops when the serum bilirubin level exceeds the binding capacity of albumin, causing
an increase in free unconjugated (or indirect) bilirubin, which can cross the immature blood-brain barrier and damage
brain cells
–In newborn infants, NHB can result from one or a combination of the following factors:
- Reduced glucuronyl transferase, a liver enzyme that breaks down bilirubin into a form that can be removed through the
bile
- Lack of intestinal flora that can break bilirubin down into urobilinogen which is then excreted in the feces
- Lower albumin concentration than in older children and adults, and therefore a reduced capacity for binding bilirubin
- Poor caloric intake/dehydration due to inadequate or unsuccessful breastfeeding, which results in slowed elimination
of bilirubin through the intestines and reabsorption of bilirubin into the circulation; this type of hyperbilirubinemia
typically peaks on days 3–5 of life and resolves by 2 weeks of age with successful feeding
- The AAP recommends that mothers nurse infants at least 8–12 times daily for the first several days of life.
Supplementing with water or dextrose water should be avoided in non-dehydrated,breastfed infants, as it does not
lower bilirubin levels. Supplementing with a milk-based formula is indicated if insufficient calories are consumed
through breastfeeding
- Bruising, which may be commonly seen after birth trauma from vacuum- or forceps-assisted deliveries. Additionally,
preterm infant blood vessels are more fragile and susceptible to breakage, with increased risk for subsequent bruising.
Elevated bilirubin levels result when damaged RBCs cannot be quickly eliminated
- Preterm delivery. Newborns of younger gestational age are physiologically immature and less capable of metabolizing
and excretingbilirubin
- Hemolytic disease, including Rh isoimmunization (i.e., maternal-infant blood type incompatibility in the presence of
maternal antigens) and glucose-6-phosphate dehydrogenase (G6PD) deficiency (i.e., an X-linked inherited enzyme
deficiency that increases the likelihood of RBC hemolyzation). In these cases, jaundice develops within 24 hours of
birth and newborns are at significant risk for severe NHB
- AAP guidelines recommend that all pregnant women should be tested for ABO and Rh blood types prenatally. If
prenatal testing was not performed, Rh typing of the infant’s cord blood should be performed to identify risk for Rh
disease
• Signs and symptoms of NHB
–The most common sign of hyperbilirubinemia is jaundice , a yellow discoloration of the skin. Jaundice progresses in a
cephalocaudal manner, from head to toe; if jaundice is present on the newborn’s forehead only, the bilirubin level can be
anticipated to be relatively low (e.g., 5–6 mg/dL). Jaundice of the trunk and extremities indicates a dangerously elevated
level of serum bilirubin. The AAP recommends assessment for jaundice be performed whenever vital signs are conducted
but no less than every 8–12 hours, and, if jaundice is present, the newborn should undergo TSB testing
–
–To assess for jaundice, use digital pressure to blanch the skin, which will reveal the underlying color of the skin. It is more
difficult to identify jaundice in darkly-pigmentedinfants. Because estimating the degree of jaundice can be difficult, some
facility protocols dictate that TSB levels be obtained for all newborns
• NHB is generally defined as a total serum bilirubin (TSB) level > 5 mg/dL, but TSB levels must be evaluated in the context
of the newborn’s gestational age and hours of life; elevated bilirubin is common in the days following birth with preterm
newborns being more likely to have elevated bilirubin levels than term newborns. TSB > 20 mg/dL is associated with a
greater risk for neurotoxicity
–Measuring the serum TSB concentration is the gold standard for clinical decision-making. A transcutaneous bilirubin
(TcB) level can be obtained noninvasively and provides an estimate of the serum TSB level. Though less precise, TcB
levels are considered adequate for screening in the majority of newborns who have TSB levels less than 15 mg/dL. For
more information on TcB testing, see Nursing Practice & Skill … Hyperbilirubinemia: Monitoring in the Newborn
• Benefits of phototherapy and safe use of phototherapy in newborns with NHB
–Because biliblankets lower TSB levels more gradually than traditional fluorescent bulb devices, treatment with a
biliblanket is generally indicated for newborns with only mild NHB (i.e., mild jaundice). Multiple biliblankets—or a
biliblanket in combination with an overhead phototherapy light—may be used for more severe cases of NHB
–Phototherapy works to lower levels of unconjugated bilirubin in 3 ways: by bleaching bilirubin (a process called
photooxidation), by changing bilirubin isomers to photoisomers which are excreted in bile, and by breaking down
bilirubin to water-soluble lumirubin which is then excreted in the urine
–The eyes must be covered while undergoing phototherapy because exposure to fluorescent light can cause retinal damage
–Follow-up TSB levels should be assessed every 12–24 hours during therapy, and 12–24 hours after discontinuation of
therapy because TSB levels may rebound after treatment
–Blanket irradiance level is measured using a radiometer (e.g., Ohmeda Biliblanket Meter). The best results are achieved
when the biliblanket’s irradiance is between 430–493 nm (American Academy of Pediatrics, 2004)
–Although phototherapy is generally safe, adverse effects/complications can occur. Note that these adverse effects are
more associated with standard phototherapy devices than with biliblankets; however, clinicians should remain alert for the
following potential complications:
- Insensible water loss. The patient’s fluid intake and urine should be monitored, and infant formula may be supplemented
depending upon the patient’s weight, urine output, and urine specific gravity
- Fecal water loss resulting in loose stools. Again, fluid supplementation may be necessary in some newborns
- Retinal damage. Eye patches or other protective eyewear should be worn by the newborn when undergoing
phototherapy to avoid retinal damage. It is important to ensure that eye patches are securely placed and not dislodged,
leaving the eyes uncovered or potentially covering the nares
- Protective eyewear is not indicated for personnel working in the vicinity of phototherapy lights
- Increase in skin circulation, resulting in redistribution of blood flow. In premature, high-risk infants this can lead to
hemodynamic instability
- Hypocalcemia can occur in premature infants as a result of abnormal melatonin (skin pigment) metabolism
- Burns resulting from malfunctioning equipment
› Preliminary steps that should be accomplished prior to using a biliblanket include the following:
• Review facility/unit-specific protocol for use of a biliblanket and newborn eye protection (e.g., use of eye patches) when
using phototherapy, if available
• Review the treating clinician’s order for biliblanket therapy
–Note specific timing of follow up TSB/TcB assessments
• Review the patient’s medical/health history for
–birth history (e.g., use of forceps)
–laboratory test results (e.g., TSB level)
–any allergies (e.g., to latex or other substances); use alternative materials as appropriate
• Review the instructions for all equipment to be used and verify that the equipment is in good working order
• Verify completion of facility informed consent documents. Typically, treatments for NHB are included in the general
consent for neonatal care
› Gather the necessary supplies, which typically include the following:
• Nonsterile gloves and other personal protective equipment (PPE; e.g., gowns) as necessary to prevent exposure to body
fluids
• Facility-approved and developmentally appropriate pain assessment tool
• Biliblanket system, including disposable pad cover
• Radiometer
• Protective eye mask/patches
• Thermometer
• Supplies for heel stick phlebotomy for TSB tests
• Equipment for assessment of vital signs, physical examination, and measuring intake/output (e.g., measuring tape, pediatric
growth chart, bed scale)
• Supplemental infant formula, if ordered for dehydration
• Written educational materials for the parents, if available
How to Use a Biliblanket
› Perform hand hygiene and dons PPE
› Identify the patient using facility protocol
› Establish privacy by closing the door to the patient’s room and/or drawing the curtain surrounding the patient’s crib/isolette
› Introduce yourself to the parents and assess the coping ability of the family. Assess for knowledge deficits and anxiety
regarding the purpose of phototherapy, as needed
• Determine if the patient/family requires special considerations regarding communication (e.g., due to illiteracy, language
barriers, or deafness); make arrangements to meet these needs if they are present
–Follow facility protocols for using a professional certified medical interpreter, either in person or via phone, when a
language barriers exists
• Explain the use of a biliblanket, its purpose, and what outcome to expect from the procedure; answer any questions and
provide emotional support as needed
–Provide explanation about the need for eye protection when administering phototherapy, the need to collect blood samples
by heel stick in order to monitor the effectiveness of treatment, and the possible need to provide supplemental infant
formula in addition to breast milk, if ordered for dehydration
› Position the patient for comfort and accessibility; raise the crib/isolette to a height that is optimal for patient access
› Assess the patient’s general health status, including vital signs and his/her pain level using a facility-approved,
developmentally appropriate pain assessment tool• Perform physical assessment, including skin appearance, and for signs of water loss or dehydration (e.g., diminished skin
turgor; < 6–8wet diapers daily; dry, parched mouth and lips; sunken anterior and posterior fontanels; transient skin rashes;
priapism in males; and loose, greenish stools); assess fluid intake and output and infant weight
• Assess for and determine the degree of jaundice. Assess for other symptoms of NHB or general (e.g., diminished activity
level, poor feeding and growth, lethargy, fever, and hypo- or hypertonia) and communicate abnormalities to the treating
clinician
› Place the illuminator on a hard, non-absorbent surface (e.g., bedside table)
› Inspect the biliblanket pad for tears or other damage and place the disposable cover on the pad. Change the disposable cover
if it becomes soiled and per the manufacturer’s instructions
› Connect the pad to the cable and the cable to the illuminator; plug in the illuminator
› After setting up the biliblanket system, perform hand hygiene and don new PPE, as appropriate. Observe standard
precautions throughout the procedure
› Place an eye shield over the newborn’s eyes to protect them from the light, per facility protocol; verify that the newborn’s
nostrils are not obstructed
• Assess the correct placement of the eye shield hourly
› Undress the newborn or lift clothing up to expose the torso; leave the diaper in place
› Position the newborn in the crib or incubator with his/her torso covering the biliblanket pad. If clothing is left on, position it
over the fiberoptic pad so that the pad remains against the newborn’s skin
› Turn on the device and set the intensity knob on the light box according to the treating clinician’s orders. Use the radiometer,
according to manufacturer’ instructions, to verify the irradiance level is as prescribed
› Monitor the position of the pad every 2 to 4 hours, repositioning it as necessary to maintain maximum skin contact
› Encourage and assist parents/guardians to visit with and care for their newborn. Explain that the fiberoptic pad is left in place
and operational when repositioning or feeding the infant, but removed when bathing and during diaper changes
• Promote newborn-parent emotional bonding and touch, as parents may be fearful of or intimidated by the presence of the
biliblanket system
› Frequently monitor vital signs, according to unit-specific/facility protocol. Assess skin appearance under the biliblanket and
for signs of water loss or dehydration
• Monitor fluid intake and output (e.g., especially for loose stools and fewer wet diapers) and infant weight
• Promote feeding according to unit-specific/facility protocol; supplement with infant formula as ordered by the treating
clinician to maintain adequate hydration
› Draw blood for TSB level or perform TcB test every 12–24 hours while biliblanket is in use;communicate laboratory results
to the treating clinician and make adjustments to the treatment regimen as ordered
• If ordered, obtain specimens for supplemental laboratory tests (e.g., cord blood testing for G6PD, albumin level,
blood type and crossmatch) that may be ordered in the care of infants with severe NHB or comorbid conditions (e.g.,
hepatosplenomegaly, thrombocytopenia, or other findings suggestive of hepatobiliary disease or metabolic disorder)
› Discard used materials and perform hand hygiene
› Prior to discharge, provide education to parents on causes of NHB, importance of early treatment, and the importance of
adherence to follow-up evaluation (see What to Tell the Newborn’s Parents, below)
› Update the newborn’s plan of care, if appropriate, and document the following in the medical record:
• Physical assessment findings, including presence and degree of jaundice and other signs and symptoms that may be present
• Results of laboratory and diagnostic studies, and how and when results were communicated to the treating clinician
• Use of the biliblanket, including duration of exposure and irradiance level
• Infant intake and output, including number and weight of wet diapers; any supplemental formula feedings provided for
dehydration
• Any unexpected patient events or outcomes, interventions performed, and whether or not the treating clinician was notified
• Family education, including topics presented, response to education, plan for follow-up education, and details regarding
any barriers to communication and/or techniques that promoted successful communication
Other Tests, Treatments, or Procedures That May Be Necessary Before or After Using
a Biliblanket
› The TSB or TcB levels are tested 12–24 hours after the completion of phototherapy
› Newborns with elevated TSB test results or other pathologic findings may require additional laboratory and diagnostic
studies, including the following:
• Bilirubin fractions (e.g., conjugated and unconjugated bilirubin)
• CBC (hemoglobin and hematocrit, reticulocyte count)
• Culture and sensitivity tests for infection
• Direct antiglobulin test (DAT) test (direct Coombs test)
• End-tidal carbon monoxide in breath (ETCO), which provides an index of bilirubin production
• Liver function tests for hepatic disease
• Peripheral blood film for erythrocyte morphology
• Serum albumin levels (an adjunct to TSB test as albumin binds bilirubin in a ratio of 1:1)
› Additional treatments that may be performed for NHB include conventional phototherapy, intravenous immunoglobulin, and
exchange blood transfusion
What to Expect After Using a Biliblanket
› TSB levels will return to the normal range, signs and symptoms of NHB will remit, and the newborn will experience no
harmful effects of NHB
Red Flags
› Ensure that the newborn’s eyes are entirely covered by the eye mask and that the nostrils are not obstructed so that the
newborn’s airway is not compromised
› Visual assessment for jaundice can be unreliable and is particularly difficult in darkly-pigmented newborns
› Monitor the newborn for signs of dehydration (i.e., < 6–8 wet diapers daily, dry, parched mouth and lips, sunken anterior
and posterior fontanels)
What Do I Need to Tell the Patient/Patient’s Family?
› Provide teaching about newborn jaundice; reassure parents that jaundice is extremely common, especially in breastfed
infants. Parents should promptly notify the treating clinician if jaundice worsens, does not resolve after 2 weeks time, or if
other signs and symptoms (e.g., poor feeding, hypotonia) develop
› For parents of newborns undergoing phototherapy, reinforce the treating clinician’s explanation of the cause of NHB and the
treatment regimen
• Reassure parents that they are not to blame for their child having NHB. This is particularly important if breastfeeding has
been unsuccessful and/or if a change to bottle-feeding has been recommended
• Explain that early identification and treatment of NHB can allow for optimal treatment and normal development
• Stress the importance of adherence to the prescribed treatment regimen and follow-up appointments
References
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Pediatrics, 128(4), 1046-1052.
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