Hyperbilirubinemia

Prévia do material em texto

NURSING
PRACTICE &
SKILL
Authors
Carita Caple, RN, BSN, MSHS
Cinahl Information Systems, Glendale, CA
Tanja Schub, BS
Cinahl Information Systems, Glendale, CA
Reviewers
Rosalyn McFarland, DNP, RN, APNP,
FNP-BC
Cinahl Information Systems, Glendale, CA
Lee Allen, RN, MS
Glendale Adventist Medical Center,
Glendale, CA
Nursing Practice Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA
June 17, 2016
Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2016, 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
Hyperbilirubinemia: Monitoring in the Newborn
What is Involved in Monitoring for Hyperbilirubinemia in the
Newborn?
› Newborns have a limited ability to completely metabolize and excrete bilirubin, which
is a by-product of erythrocyte (i.e., red blood cell) breakdown that binds to albumin
and is eliminated via the liver. Neonatal hyperbilirubinemia (NHB;i.e., increased
concentration of unconjugated bilirubin in circulating blood of the newborn) occurs
in almost two-thirdsof infants, but severe NHB is toxic and can lead to complications
ranging from mild to life-threatening (e.g., bilirubin encephalopathy). Methods of
screening for NHB and determining risk for severe NHB include assessing for jaundice
(i.e., yellowing of the skin and whites of the eyes) and measuring the infant’s total serum
bilirubin (TSB) level or transcutaneous bilirubin (TcB) level
• What: The first and most common sign of hyperbilirubinemia is jaundice, but jaundice
can be difficult to detect or quantify, especially in non-White infants; jaundice is
also extremely common in newborns and is usually benign. Diagnostic testing and
monitoring is particularly important when clinical suspicion for severe NHB exists
• How: Guidelines published by the American Academy of Pediatrics (AAP) recommend
universal screening for NHB before discharge by performing TSB or TcB. The TSB
level is determined through blood sampling and laboratory analysis. The TcB level can
be obtained using a bilirubinometer, which is a handheld device that noninvasively
estimates the concentration of bilirubin in the skin
• Where: Monitoring newborns for hyperbilirubinemia is performed in the newborn
nursery, postpartum unit, neonatal intensive care unit (NICU), outpatient clinic,
emergency department, and at home during follow-up care
• Who: Licensed nurses and treating clinicians are involved in assessing the newborn and
monitoring for hyperbilirubinemia. These responsibilities should not be delegated to
assistive/unlicensed staff members. It is appropriate for family members to be present
during NHB assessment and monitoring
What is the Desired Outcome of Monitoring for
Hyperbilirubinemia in the Newborn?
› The desired outcome of monitoring for hyperbilirubinemia is to identify
hyperbilirubinemia and assess risk for severe NHB in order to provide prompt treatment
Why Is Monitoring for Hyperbilirubinemia in the Newborn
Important?
› NHB can lead to multiple sequelae, the most severe of which is bilirubin encephalopathy
(commonly called kernicterus). Kernicterus is a rare neurologic disorder that affects
the basal ganglia and brainstem nuclei. In the acute phase of kernicterus, the newborn
is severely jaundiced, lethargic, and hypotonic and has poor feeding. If severe NHB is
not corrected, the infant develops hypertonia, which is characterized byretrocollis (i.e.,
backward arching of the neck) and opisthotonus (i.e., backward arching of the trunk), and
may develop a fever and a high-pitchedcry. Surviving infants usually develop a severe
form of choreoathetoid cerebral palsy characterized by an upward gaze and twisting
movements of the forelimbs; mental retardation, deafness, and spastic quadriplegia can
develop. (For more information on kernicterus, see Quick Lesson About … Kernicterus )
Facts and Figures
› Investigators who studied 982 healthy, racially/ethnically diverse infants at 6 large United States medical centers reported
jaundice to be very common, occurring in 84% of healthy newborns during the first week of life. Despite a high frequency
of jaundice, only 7.6% of infants had clinical factors, including TcB and TSB levels, that were concerning enough to warrant
treatment with phototherapy (Bhutani et al., 2013)
› Investigators who analyzed 2,454 TcB measurements from 419 newborns before the development of severe NHB
reported that TcB increases during the first 36–48 hours after delivery were often attributed to maternal-infant Rh blood
incompatibility or glucose-6-phosphate dehydrogenate (G6PD) deficiency (i.e., an X-linked inherited enzyme deficiency
that increases the likelihood of erythrocyte hemolyzation and is characterized by jaundice). Later increases in TcB levels
were found among younger gestational age newborns, newborns who had weight loss, or newborns who were exclusively
breastfed (Mantagou et al., 2012)
› It is generally recommended that TcB measurements not be used following phototherapy treatment because the treatment can
reduce the accuracy of results; however, one group of investigators determined that TcB measurements were comparable to
TSB measurements both before and after phototherapy (Fonseca et al., 2012)
› Kernicterus affects 0.4–2.7 per 100,000 births in North America and Europe (Hansen, 2016)
› The AAP recommends that healthcare organizations establish standing nursing protocols to test for NHB in jaundiced
infants (AAP, 2004) because doing so may improve timeliness of treatment. Researchers compared outcomes in 149
infants presenting to the emergency department with jaundice during the 9-month period before implementation of a
nursing-initiated clinical pathway with 151 infants who presented during the 9-month period after initiation of the pathway.
The clinical pathway included triage nurse assignment of all neonates presenting with jaundice or NHB to high level of
triage priority, bedside nurse initiation of parent education, request for an order for TSB measurement prior to physician
evaluation, and phototherapy with a bilirubin blanket immediately following serum sample collection. The investigators
found that implementation of the pathway led to significant reductions in median time to phototherapy (128 minutes vs. 52
minutes), median time to bilirubin results (157 minutes vs. 99 minutes), and median emergency department length of stay
(268 minutes vs. 195 minutes)(Wolff et al., 2012)
What You Need to Know Before Monitoring for Hyperbilirubinemia in the Newborn
› Prior to monitoring for NHB in the newborn, the nurse clinician should be familiar with the following:
• Pathophysiology of NHB in the newborn and factors that increase risk for severe NHB
–NHB results when the serum bilirubin level exceeds the binding capacity of albumin. Free unconjugated or indirect
bilirubin can cross the immature blood-brain barrier and damage brain cells
–In newborn infants, NHB can result from any of the following factors:
- Poor caloric intake and dehydration due to inadequate or unsuccessful breastfeeding, which results in slowed elimination
of bilirubin through the intestines and reabsorption of bilirubin in circulation; this type of NHB typically peaks on days
3–5 of life and resolves by 2 weeks of age with successful feeding
- The AAP recommends that mothers nurse their infants at least 8–12 times daily for the first several days of life.
Supplementing withwater or dextrose water should be avoided in nondehydrated, breastfed infants because it does
not lower bilirubin levels. Supplementing with a milk-basedformula is indicated if insufficient calories are consumed
through breastfeeding
- Cephalohematoma or birth trauma with bruising. Elevated bilirubin levels result when damaged RBCs cannot be quickly
eliminated
- Preterm delivery. Newborns < 38 weeks’ gestational age are physiologically immature and less capable of metabolizing
and excreting bilirubin
- Hemolytic disease, including Rh isoimmunization (i.e., maternal-infant blood type incompatibility and presence of
maternal antigens) and G6PD deficiency. In these cases, jaundice develops within 24 hours of birth and risk is much
greater 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 infant cord blood should be performed to identify risk for Rh disease
- Additional risk factors for NHB include family history of neonatal jaundice, Asian ethnicity, maternal age > 25 years,
and male sex of the newborn
• The signs and symptoms of NHB, including having an understanding of normal and abnormal TSB levels
–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
- To assess for jaundice, use digital pressure to blanch the skin in order to see the underlying color of the skin
- It is difficult to identify jaundice in darkly-pigmented infants using digital pressure; instead, the color of the sclera,
conjunctiva, and oral mucosa is considered the most reliable indicator
- The nurse should assess the infant for jaundice in natural daylight (e.g., with window curtains open) for a true
assessment of color whenever possible
- Because estimating the degree of jaundice can be difficult, some facility protocols dictate that TSB or TcB levels be
obtained for all newborns
–NHB is generally defined as a 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,and preterm newborns
are more likely to be jaundiced or have elevated bilirubin levels than term newborns. To assess risk for severe NHB,
measured TSB levels can be plotted on a nomogram that provides hour-specific risk estimates for elevated bilirubin levels
in preterm and term infants. The following simplified chart can also be used to identify the TSB level at which additional
laboratory and other diagnostic tests may be warranted:
.
TSB level (mg/dL) Newborn age (hours)
> 10 < 24
> 12 24-48
> 15 29-72
> 17 > 72
.
–Measuring the TSB concentration is the gold standard for clinical decision-making. The TcB test provides an estimate
of the TSB level and is less precise, but is considered adequate for screening in the majority of newborns who have TSB
levels that are < 15 mg/dL. Newer bilirubinometers provide results that are within 2–3 mg/dL of serum level results
• The procedure for heel stick blood sampling in the newborn, which is necessary to perform TSB testing. (For information,
see Nursing Practice & Skill … Blood Sampling in the Newborn or Infant: Heel Puncture -- Performing )
• Use of a bilirubinometer, which is used to obtain TcB level
–Bilirubinometers are handheld computerized devices that work by placing a light-emitting sensor against the infant’s
forehead or sternum to measure the concentration of bilirubin in the skin tissues. The light reflected back toward the
device is analyzed by an optical detector in multiple wavelengths, as skin tissues containing bilirubin emit light at a
different wavelength than tissues not containing bilirubin. The TcB level is then displayed on a digital or touchscreen in
mg/dL or mmol/L. Two or five measurements are taken in succession depending on manufacturer instructions or facility
protocol and averaged to obtain the TcB level
- Areas of the skin with bruising, birthmarks, hematomas, or hair should be avoided because they can affect the accuracy
of results. Measurements can be obtained from the forehead or mid-sternum
- Bilirubinometers are useful for screening but not for monitoring following exposure to sunlight or after phototherapy has
been initiated
- Second generation bilirubinometers, which are in clinical use today, correlate well with TSB and can be effectively
utilized for neonates of all ethnic backgrounds/skin colors
• Knowledge of and demonstrated competence in adherence to standard precautions in health care and aseptic technique
› Preliminary steps that should be performed before monitoring for NHB in the newborn include the following:
• Review the facility protocol for neonatal care and screening, if one is available
• Review the treating clinician’s order for TSB/TcB testing
• Review manufacturer 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, the general consent for obstetric and neonatal care includes standard provisions for performing screening
laboratory studies
› Gather supplies, which typically include the following:
• Nonsterile gloves and additional personal protective equipment (PPE; i.e., gloves, eye protection, gown, and mask) may be
needed if exposure to body fluids is anticipated
• Supplies for heelstick phlebotomy for serum tests
• Bilirubinometer unit and batteries
• Patient’s medical record
• Equipment for assessment of vital signs and performing a physical examination (e.g., measuring tape, pediatric growth
chart, bed scale)
• Written educational materials for the parents, if available
How to Monitor for Hyperbilirubinemia in the Newborn
› Perform hand hygiene
› Identify the patient according to facility protocol
› Introduce yourself to the parents, if present, and explain your clinical role; assess for knowledge deficits and anxiety
regarding bilirubin screening
• Determine if the parents require 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 protocol for use of professional certified medical interpreters, either in person or via phone, when
language barriers exist
• Explain the procedure, its purpose, and what outcome to expect from the procedure to the parents; answer all questions and
provide emotional support and additional information as needed
–Explain that blood samples will be obtained by heelstick, but should not cause the infant prolonged discomfort
› Observe standard precautions throughout the procedure
› Don nonsterile gloves and other PPE as appropriate
› Perform a complete physical examination on the newborn using natural ambient light for visual inspection if possible
• Assess for jaundice and for other signs of NHB or general illness. Assess for diminished activity level, poor feeding and
growth, lethargy, fever, and hypo- or hypertonia
• If the mother is breastfeeding, ask about the newborn’s appetite, frequency of feedings, and ability to latch on
› Facilitate completion of laboratory and diagnostic tests as ordered or per facility protocol
• Assist with screening for NHB by obtaining a heelstick specimen for serum measurement of TSB level or by performing a
TcB test
–Perform the following for a TcB test:
- Perform self-test and calibrate the device according to manufacturer directions
- Hold the bilirubinometer device sensor to the skin of the forehead or mid-sternum for up to 5 seconds (or according to
manufacturer directions for the specific device) until a beepis heard; avoid areas of the skin with bruising, birthmarks,
hematomas, or hair
- Note the reading on the digital or touchscreen
- Repeat the test 2–5 times as indicated, then average the results to obtain the TcB level
• If ordered, obtain specimens for supplemental laboratory tests (e.g., cord blood testing for G6PD deficiency, albumin level,
blood type and crossmatch) that may be ordered in the care of infants with severe NHB or infants with comorbid conditions
(e.g., hepatosplenomegaly, thrombocytopenia, or other findings suggestive of hepatobiliary disease or metabolic disorder)
› Administer treatment to newborns with severe NHB, as ordered, which may include
• phototherapy for infants whose bilirubin level reaches the threshold for treatment, as prescribed. (For information on
phototherapy, see Nursing Practice & Skill … Biliblanket: Using )
• formula or expressed breast milk feedings for infants with > 12% weight loss following birth or evidence of dehydration
• intravenous immunoglobulin for infants with isoimmune hemolytic disease
• exchange blood transfusion for infants with hemolytic anemia
› Dispose of used materials in proper receptacles and perform hand hygiene
› Update the newborn’s plan of care, if appropriate, and document monitoring for NHB in the patient’s medical record,
including the following information:
• Date and time of monitoring and each intervention
• Description of each monitoring procedure and treatments administered, including time, dose, and route
• Patient assessment findings, including presence and degree of jaundice and other signs and symptoms, results of laboratory
and diagnostic studies, and how and when results were communicated to the treating clinician
• Laboratory specimens collected and sent for analysis
• Any unexpected patient events, interventions performed, whether or not the treating clinician was notified, and patient
outcome
• All parent education provided, including topics presented, response to education, plan for follow-up education, barriers to
communication, and techniques that promoted successful communication
Other Tests, Treatments, or Procedures That May Be Necessary Before or After
Monitoring for Hyperbilirubinemia in the Newborn
› 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 for hemoglobin, hematocrit, and reticulocyte count
• Culture and sensitivity tests for infection
• Direct antiglobulin test (DAT; also called direct Coombs test)
• End-tidal carbon monoxide in breath (ETCO), which provides an index of bilirubin production
• Liver function tests to assess for hepatic disease
• Peripheral blood film for erythrocyte morphology
• Serum albumin levels, which is an adjunct to a TSB test because albumin binds bilirubin in a ratio of 1:1
What to Expect After Monitoring for Hyperbilirubinemia in the Newborn
› Screening for NHB is performed on all newborns within 24 hours of birth, and elevated bilirubin levels are identified
› Severe NHB will be detected and treated prior to development of complications
Red Flags
› Visual assessment for jaundice is unreliable and should not be performed in assessment of darkly-pigmented newborns
› Newborns with extremely elevated TcB levels should immediately undergo TSB testing to assess serum bilirubin level
› Parents should be educated on the signs and symptoms of NHB because severe NHB can develop after discharge
What Do I Need to Tell the Newborn’s Parents?
› Educate the newborn’s parents about NHB screening methods and their indications
› Provide the following education about newborn jaundice to parents:
• Jaundice is extremely common, especially in breastfed infants
• Jaundice usually does not require treatment, but parents should promptly notify the treating clinician if jaundice worsens,
does not resolve after two weeks’ time, or if other signs and symptoms (e.g., poor feeding, hypotonia) develop
› Reinforce the treating clinician’s explanation of the cause of NHB and the treatment regimen, and 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. Emphasize
the importance of adherence to the prescribed treatment regimen and keeping follow-up appointments
References
1. Alden, K. R. (2014). Nursing care of the newborn and family. In S. E. Perry, M. J. Hockenberry, D. L. Lowdermilk, & D. Wilson (Eds.), Maternal child nursing care (5th ed., pp.
605-608). St. Louis, MO: Elsevier Mosby.
2. Alfanetti, M., Eleni Dit Trolli, S., Yousef, N., Jrad, I., & Mokhtari, M. (2014). Transcutaneous bilirubinometry is not influenced by term or skin color in neonates. Early Human
Development, 90(8), 417-420. doi:10.106/j.earlhumdev.2014.05.009
3. American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia. (2004). Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation.
Pediatrics, 114(1), 297-316. doi:10.1542/peds.114.1.297
4. Bhutani, V. K. (2011). Phototherapy to prevent severe neonatal hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics, 128(4), 1046-1052.
doi:10.1542/peds.2011-1494
5. Bhutani, V. K., Stark, A. R., Lazzeroni, L. C., Poland, R., Gourley, G. R., Kazmierczak, S., ... Stevenson, D. K. (2013). Predischarge screening for severe neonatal
hyperbilirubinemia identifies infants who need phototherapy. Journal of Pediatrics, 162(3), 477-482. doi:10.1016/j.jpeds.2012.08.022
6. Fonseca, R., Kyralessa, R., Malloy, M., Richardson, J., & Jain, S. K. (2012). Covered skin transcutaneous bilirubin estimation is comparable with serum bilirubin during and
after phototherapy. Journal of Perinatology, 32(2), 129-131. doi:10.1038/jp.2011.66
7. Hansen, T. W. R. (2016, March 4). Neonatal jaundice. Medscape. Retrieved June 2, 2016, from http://emedicine.medscape.com/article/974786-overview
8. Kuzniewicz, M. W., Escobar, G. J., & Newman, T. B. (2009). Impact of universal bilirubin screening on severe hyperbilirubinemia and phototherapy use. Pediatrics, 124(4),
1031-1039. doi:10.1542/peds.2008-2980
9. Maisels, M. J., Bhutani, V. K., Bogen, D., Newman, T. B., Stark, A. R., & Watchko, J. F. (2009). Hyperbilirubinemia in the newborn infant #35 weeks’ gestation: An update with
clarifications. Pediatrics, 124(4), 1193-1198. doi:10.1542/peds.2009-0329
10. Mantagou, L., Fouzas, S., Skylogianni, E., Giannakopoulos, I., Karatza, A., & Varvarigou, A. (2012). Trends of transcutaneous bilirubin in neonates who develop significant
hyperbilirubinemia. Pediatrics, 130(4), e898-e904. doi:10.1542/peds.2012-0732
11. U.S. Preventive Services Task Force. (2009). Screening of infants for hyperbilirubinemia to prevent chronic bilirubin encephalopathy: US Preventive Services Task Force
recommendation statement. Pediatrics, 124(4), 1172-1177. doi:10.1542/peds.2009-0128
12. Wilson, D., & Wilson, K. D. (2015). Health problems of newborns. M. J. Hockenberry & D. Wilson (Eds.), Wong’s nursing care of infants and children (10th ed.). St. Louis, MO:
Mosby Elsevier.
13. Wolff, M., Schinasi, D. A., Lavelle, J., Boorstein, N., & Zork, J. J. (2012). Management of neonates with hyperbilirubinemia: Improving timelines of care using a clinical pathway.
Pediatrics, 130(6), e1688-1694. doi:10.1542/peds.2012-1156