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156 Cards in this Set
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Criteria for PHYSIOLOGIC JAUNDICE |
1. Appears on Day 2 to Day 3 2. Rate: < 5 mg/dL/day 3. Peaks on Day 3 to Day 5 4. Peak level: 7-7.5 mg/dL 5. Goes down from 5th-7th 6. Level at 5th-7th: max of 2 mg/dL |
5 |
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THREE BIG CATEGORIES of why Neonates are more prone to Jaundice |
1. Blood Conditions 2. Conjugation and Excretion 3. Transportation |
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Blood Conditions of Why Neonates are more prone to jaundice |
1. More RBC 2. More bilirubin 3. Shorter RBC Life |
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Level of RBC |
16-18 mg/dL |
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Level of Bilirubin in Neonates |
6-8 mg/dL |
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Life of RBC |
90 days |
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TRANSPORTATION REASONS of Why Neonates are more prone to jaundice |
1. Low albumin levels 2. Low affinity of albumin 3. Competition of Albumin |
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WHY CONJUGATION AND EXCRETION? |
Low levels of glucuronyl transferase |
Low levels of _____ |
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Criteria for CHOLESTATIC JAUNDICE |
If CONJUGATED BILIRUBIN is >20% |
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When does BREAST FEEDING JAUNDICE seen |
3rd to 4th day of life |
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Causes of Breastfeeding Jaundice |
1. Poor feeding 2. Decreased stool output 3. Increased enterohepatic circulation |
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Three broad caused of NEONATAL JAUNDICE |
1. Overproduction of bilirubin 2. Undersecretion of bilirubin 3. Mixed |
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Causes of OVERPRODUCTION OF BILIRUBIN |
1. Hemolytic 2. Extravasation of blood 3. Polycythemia 4. Enterohepatic circulation |
HEPE |
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Causes of UNDERSECRETION OF BILIRUBIN |
1. Transport 2. Uptake 3. Conjugation 4. Obstruction |
TUCO |
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Causes of MIXED LEADING TO JAUNDICE |
1. Intrauterine infection 2. Multisystem disorders 3. Postnatal infection |
MIMP |
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Causes of HEMOLYSIS leading to Jaundice |
1. ABO Incompatibility 2. Drug Induced 3. Genetic |
3 |
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GENETIC Causes of HEMOLYSIS leading to Jaundice |
1. Spherocytosis 2. Hemoglobinopathy 3. Enzyme deficiency 4. Galactosemia |
SHEG the blood |
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What causes EXAGGERATED ENTEROHEPATIC CIRCULATION |
1. Mechanical obstruction 2. Reduced peristalsis |
2 |
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Classification of SIGNIFICANT HYPERBILIRUBINEMIA |
> 95th percentile > 17th mg/dL |
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Classification of SIGNIFICANT HYPERBILIRUBINEMIA |
> 95th percentile > 17th mg/dL |
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Classification of SEVERE HYPERBILIRUBINEMIA |
> 99th percentile > 20 mg/dL |
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Classification of EXTREME HYPERBILIRUBINEMIA |
> 99.5th percentile > 25 mg/dL |
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What causes TRANSPORT IMPAIRMENT leading to jaundice |
1. Congenital (Rubin Johnson, Rotor) 2. Hepatocellular damage |
Liver stuff |
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What causes UPTAKE IMPAIRMENT leading to jaundice |
1. Cytosol receptor protein blocked 2. Persistent ductus venosus |
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What causes CONJUGATION IMPAIRMENT leading to jaundice |
1. Low glucuronyl transferase 2. Enzyme inhibitor (Criggler-Najjar, Lucey Driscoll) 3. Hypothyroidism |
3 |
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What causes BILE FLOW OBSTRUCTION leading to jaundice |
1. Biliary atresia 2. Giant cell hepatitis 3. Choledocal cyst 4. Cystic fibrosis 5. Extracellular obstruction (Tumor and band) |
5 |
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What causes INTRAUTERINE INFECTIONS |
TORCHHS Toxoplasmosis Rubella Cytomegalovirus Herpes simplex Hepatitis A and B Syphilis |
Light the way! |
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EVALUATION of pathologic jaundice |
1. CBC 2. Indirect/direct bilirubin 3. Coomb's 4. Maternal and Fetal blood typing 5. Peripheral smear 6. Reticulocyte 7. T4, TSH 8. Culture 9. Urine reducing sugar |
9 |
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Complications of Hyperbilirubinemia |
1. Bilirubin toxicity 2. Kernicterus 3. Acute bilirubin encephalopathy 4. Bilirubin-induced Neurologic Dysfunction 5. Chronic Bilirubin encephalopathy 6. Subtle bilirubin encephalopathy |
6 items |
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What can be the effects of BILIRUBIN TOXICITY |
1. Cerebral palsy 2. Developmental delay 3. Hearing impairment |
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What is KERNICTERUS |
Pathologic findings in the brain due to bilirubin toxicity |
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Kernicterus is used to refer to what |
Chronic bilirubin encephalopathy with permanent neurological damage |
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Kernicterus MOI (mechanism of injury) |
Bilirubin-induced peroxidation --> Neuroinflamattion --> Mitochondrial damage --> Apoptosis --> Cell death |
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What are the symptoms of PHASE I of ABE |
1. Hypotonia 2. Poor feeding 3. Lethargy / Stupor 4. Seizures |
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What are the symptoms of PHASE II of ABE |
1. Alternating hypertonia and hypotonia 2. Back and neck arching 3. Opisthotonus 4. Retrocollis 5. Fever 6. High pitched cry 7. Upward gaze 8. Muscle spasms |
8 |
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What are the symptoms of PHASE III of ABE |
After 1 week 1. Hypertonia |
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DEFINITIVE SYMPTOMS of ABE |
1. BAER 2. Lesions on globus pallidum on MRI |
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What is BILIRUBIN INDUCED NEUROLOGIC DYSFUNCTION |
Subtle form of brain injury with less obvious neurologic manifestations |
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What does the grade of <6 in BIND mean |
Reversible, with complete resolution |
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What does the grade of >6 in BIND mean |
Irreversible |
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BIND: EARLY CATERGORY of Mental Status |
Sleepy + Poor feeding |
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BIND: INTERMEDIATE CATERGORY of Mental Status |
Lethargy + Irritability |
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BIND: LATE CATERGORY of Mental Status |
Semi coma and seizures |
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BIND: EARLY CATERGORY of muscle tone |
Hypotonia |
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BIND: INTERMEDIATE CATERGORY of muscle tone |
Hyper/Hypotonia Mild Nuchal / Trunchal Arching |
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BIND: LATE CATERGORY of muscle tone |
Hypertonia Bicycling Opisthotonus |
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BIND: EARLY CATERGORY of cry |
High pitched |
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BIND: INTERMEDIATE CATERGORY of cry |
Shrill |
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BIND: LATE CATERGORY of cry |
Inconsolable |
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What is the clinical tetrad of clinical sequelae in Chronic Bilirubin Encephalopathy |
1. Impaired upward gaze 2. Extrapyramidal abnormalities 3. Deafness / Hearing impairement 4. Dental enamel dysplasia |
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What are the symptoms of SUBTLE BILIRUBIN ENCEPHALOPATHY |
1. Gaze impairement 2. Gait impairment 3. Hearing loss (isolated) |
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What are the 5 reasons why bilirubin is needed/is non-polar? |
1. Fetal bilirubin is excreted via placenta 2. Iron salvage pathway 3. Scavenge for peroxidyl radical 4. Inhibit mutagens 5. Antioxidant |
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What are the byproducts of heme oxygenation |
1. Iron 2. Carbon monoxide 3. Biliverdin |
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What are the mutagens inhibited by bilirubin? |
1. Polycyclic aromatic carbon 2. Heterocyclic amine 3. Oxidants |
3!! Yummy pho |
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As an oxidant, what does bilirubin help prevent? |
Cancer and Cardiovascular Disease |
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TRAUMA TIMING Bruise is red What causes this? |
Extravasation of blood |
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TRAUMA TIMINGBruise is greenWhat causes this? |
Conversion of RBC to biliverdin |
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TRAUMA TIMINGBruise is yellowWhat causes this? |
Conversion of biliverdin to Bilirubin |
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TRAUMA TIMINGBruise is redHow long since trauma? |
0-2 days |
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TRAUMA TIMINGBruise is blueHow long since trauma? |
2-5 days |
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TRAUMA TIMINGBruise is greenHow long since trauma? |
5-7 days |
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TRAUMA TIMINGBruise is yellowHow long since trauma? |
7-10 days |
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TRAUMA TIMINGBruise is brownHow long since trauma? |
10-14 days |
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TRAUMA TIMING Color progression and their time |
Red (0-2 days) Blue (2-5 days) Green (5-7 days) Yellow (7-10 days) Brown (10-14 days) |
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Basic Principles of Preventing Severe Hyperbilirubinemia What are the principles? |
1. Identify and recognize risk factors of bilirubin encephalopathy 2. In-hospital monitoring 3. Post-discharge monitoring 4. Education of parent and nursing on risks of severe hyperbilirubinemia 5. Breastfeeding support |
5 principles |
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Basic Principles of Preventing Severe Hyperbilirubinemia How often should you check Bilirubin levels in the hospital |
Every 8 hours as part of vitals |
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Basic Principles of Preventing Severe Hyperbilirubinemia When should you checkup on baby after discharge? |
Within 48-72 hours |
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What are the main features of clinical assessment |
1. Visual assessment 2. Bilirubin testing 3. Identification of risk factors |
3 |
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KRAMER'S RULE What are the 5 zones and their levels |
Level 1 - Head Level 2 - Upper Trunk (above umbilicus) Level 3 - Lower Trunk (below umbilicus) Level 4 - arms and legs Level 5 - Palms and Soles |
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KRAMER'S RULE What is the bilirubin range if jaundice is confined to the head |
4-8 mg/dL |
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KRAMER'S RULEWhat is the bilirubin range if jaundice reaches the upper trunk |
5-12 |
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KRAMER'S RULEWhat is the bilirubin range if jaundice reaches the lower trunk |
8-16 |
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KRAMER'S RULEWhat is the bilirubin range if jaundice reaches the Arms and Legs |
11-18 |
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KRAMER'S RULEWhat is the bilirubin range if jaundice reaches the palms and soles |
>/= 18 |
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What is transcutaneous Bilirubin (TCB) |
Non invasive way to check bilirubin levels |
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TCB Indications |
AOG > 35 weeks Postnatal age >24 hours |
Time |
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When is total serum bilirubin indicated? |
1. If TCB > 250 2. If AOG < 35 weeks 3. Jaundiced within 24 hours of birth |
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What are the risk factors of developing severe hyperbilirubinemia in infants > 35 weeks |
1. 35 - 36 weeks 2. Breastfeeding with poor feeding 3. Blood group incompatibility 4. G6PD 5. East asian 6. Jaundice within 24 hours 7. Cephalhematoma with bruising 8. Sibling who received phototherapy 9. Predischarge bilirubin level in the high risk zone |
9 |
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How will you manage a baby with pre-discharge bilirubin level in the low risk zone? |
You can discharge as low risk of developing severe Hyperbilirubinemia |
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How will you manage a baby with pre-discharge bilirubin level in the high risk zone |
DO NOT DISCHARGE Consider starting interventions |
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How will you manage a baby with pre-discharge bilirubin level in the intermediate risk zone |
Don't discharge and delay Take reading again |
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Considerations for late preterm infants innterms of risk |
They are at an 8-fold risk of developing bilirubinemia increase > 20 mg/dL |
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Considerations for late preterm infants innterms of managemenr |
At 35-37 weeks, low bilirubn levels with risk factors consider phototherapy |
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Most common cause of Bilirubin that warrants phototherapy |
UNKNOWN |
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Second most common cause of Bilirubin that warrants phototherapy |
G6PD |
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What is the hour of life approach |
Management is dependent on bilirubin levels at hours after birth |
What does it consider |
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What are the values for phototherapy in a low risk infant |
24 hours: > 12 mg/dL 48 hours: > 15 mg/dL 72 hours: > 18 mg/dL |
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What are the values for exchange transfusion in a low risk infant |
24 hours: > 19 mg/dL 48 hours: > 22 mg/dL 72 hours: > 24 mg/dL >72 hours: >/= 25 mg/dL |
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What are the values for phototherapy in a high risk infant |
24 hours: > 8 mg/dL 48 hours: > 11 mg/dL 72 hours: >14 mg/dL |
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Baby is 38 weeks 24 hours after birth Bilirubin level: 32 mg/dL How will you manage? |
Exchange therapy |
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Baby is 36 weeks 72 hours after birth Bilirubin level: 2 mg/dL How will you manage? |
No need |
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Baby is 38 weeks 72 hours after birth Bilirubin level: 12 mg/dL How will you manage |
No need |
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Baby is 38 weeks 48 hours after birth Bilirubin level: 17 mg/dL How will you manage |
Phototherapy |
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What is phototherapy |
A therapy that converts bilirubin into a water soluble form without the need for conjugation and glucuronidation in the liver |
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What happens in phototherapy |
A photon of life is absorbed by bilirubin to convert it to a water soluble form without the need for liver glucuronidation |
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What are the mechanisms in phototherapy |
Photooxidation Photoisomerization |
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What happens in photoisomerization |
Configurational change Structural change |
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Describe the structure of bilirubin |
4 pyrrole rings joined by carbon bridges |
_________ joined by ________ |
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What happens in photooxidation? |
Cleaves the bridges that link the pyrrole rings together |
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Photooxidation is a _____ pathway |
Minor |
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What are the byproducts of photooxidation |
Di-pyrrole Mono-pyrrole |
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What happens in configurational photoisomerization |
Double bonds of carbon bridge --> single bond --> 180 degree rotation --> reconvert to a single bond |
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Configurational photoisomerization is a __________ reaction |
Major |
Major / minor? |
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What are the products of configurational photoisomerization? |
4 isomers |
# structure |
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Configurational photoisomerization is a ____________ reaction but excretion is __________ |
Fast reaction but excretion is slow |
Speed reaction Excretion quality |
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Why is excretion in configurational photoisomerization slow? |
Because there are 4 isomers that need to be excreted |
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What are the 4 isomers from configurational photoisomerization |
4Z, 15Z 4Z, 15E 4E, 15Z 4E, 15E |
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What is the most common isomer |
4E, 15E |
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What happens in structural photoisomerization |
Bilirubin is converted into a new structure that contains a 7 member ring (Lumirubin) |
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What do you call the 7 member ring that is found in the new structure due to structural photoisomerization |
Lumirubin |
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How does structural photoisomerization make bilirubin water-soluble |
It opens up the structure |
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Structural photoisomerization is a major/minor pathway? |
Major |
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Structural photoisomerizationreaction is irreversible/reversible? |
Irreversible |
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Structural photoisomerization is a __________ reaction and it is excreted __________ |
Slow reaction Excreted efficiently |
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What are the three ways you can optimize phototherpay |
1. Color 2. Irradiance 3. Adjunct therapy |
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What is the ideal wavelength to be used in phototherpay |
450 nm |
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What is their finding on multiple phototherapy |
It is more effective than conventional single phototherapy Leads to faster bilirubin decline |
It is ________ effective than conventional single phototherapy Leads to __________ bilirubin decline |
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What is the finding on fiberoptic phototherapy |
It is less effective than conventional phototherapy |
It is ________ effective than conventional single phototherapy |
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What are the advantages of conventional compared to fiberoptic phototherapy |
1. Less treatment failure 2. More effective 3. Shorter therapy duration |
3 things |
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What are the findings on circumferential phototherapy |
It is more effective than conventional single phototherapy |
It is ________ effective than conventional single phototherapy |
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Exposure is increased by __________ in circumferential phototherapy |
80% |
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What is the advantage of LED phototherapy |
It is cheaper as it lasts longer and has less power consumption |
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What are the findings of LED phototherapy |
It is just as effective than conventional phototherapy |
It is ________ effective than conventional single phototherapy |
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What are the advantages of fiberoptic therapy |
1. Can be wrapped around the baby 2. Does not emit heat |
2 |
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What orientation is more effective in LED phototherapy |
Overhead |
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What is the finding regarding changing baby position |
Same efficacy so turning is unnecessary |
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What is the finding about continuous vs intermittent therapy? |
It does not have a difference Interruption of therapy to feed baby is okay |
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When is continuous therapy indicated |
1. Baby has very high bilirubin levels 2. Baby was started on multiple therapy |
2 |
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What are the advantages of white curtains? |
Faster decline in serum bilirubin |
1 |
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What are the disadvantages of white curtains? |
Blocks caregiver view |
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What do you have to do to manage a patient under phototherapy |
1. Fluid replacement 2. Temperature monitoring 3. Shield eye 4. Make sure baby has maximal skin intervention 5. Monitor serum bilirubin every 6-12 hours |
5 things |
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By how much does water loss increase in phototherapy |
25-50% |
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What are some complications expected due to phototheray |
1. Tanning 2. Brown baby syndrome 3. Diarrhea 4. Hemolysis 5. Skin burn 6. Skin rashes 7. Dehydration 8. Lactose intolerance |
8 |
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What causes tanning in babies undergoing phototherapy |
Induction of melanin synthesis due to light absorption |
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What causes brown baby syndrome in babies undergoing phototherapy |
Polymerization of circulating porphyrins |
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What causes diarrhea in babies undergoing phototherapy |
Bilirubin-induced bowel secretion |
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What causes lactose intolerancein babies undergoing phototherapy |
Mucosal injury of villus epithelium |
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What causes hemolysisin babies undergoing phototherapy |
photosensitized injury to erythrocytes |
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What causes skin burnsin babies undergoing phototherapy |
Excessive exposure to short-wave emissions from fluorescent lamp |
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What causes dehydrationin babies undergoing phototherapy |
Increased water loss from absorbed photon energies |
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What causes skin rashesin babies undergoing phototherapy |
photosensitized injury to skin mast cells leading to histamine release |
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What are some ancillary therapies that can be done with phototherapy |
1. Exchange transfusion 2. IVIG 3. Clofibrate 4. Phenobarbital 5. Tin-mesophyrin 6. Prevent / decrease enterohepatic circulation |
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What happens in exchange transfusion |
Baby's blood is replaced with donor blood |
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What blood is given if there is ABO incompatibility |
Type O |
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What blood is given if there is Rh incompatibility |
Type O - |
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How much of the baby's blood is exchanged in exchange transfusion |
85% |
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Exchange transfusion can decrease bilirubin by how much |
50% |
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When is IVIG used in phototherapy |
When hyperbilirubinemia is secondary to hemolysis |
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What are the findings regarding the use of IVIG during phototherapy |
Shorter duration of phototherapy Less exchanges |
2 |
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What is clofibrate |
A lipid reducing substance |
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What does phenobarbital do |
It induces glucuronyl transferase which is used to conjugate bilirubin |
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How long does it take for phenobarbital to take it's makixum effect |
5-7 days |
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What are the overall results of phenobarbital usage |
1. Lowers total bilirubin levels 2. Shorter phototherapy duration 3. Less need for phototherapy 4. Less need for transfusions |
4 |
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What does tin-mesoporphyrin do? |
Inhibits heme oxygenase Oxidizes heme to bliverdin |
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What is used to prevent or reduce enterheaptic circulation |
1. Charcoal 2. Agar 3. Glycerin suppositories |
3 |
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What are findings regarding the stuff used to reduce enterohepatic circulation |
Not that effective |
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