Hyperbilirubinemia for RNs

Learn about hyperbilirubinemia and how we will provide phototherapy on Level 8!

Hyperbilirubinemia

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LEARNING OBJECTIVES

1. Define terms related to hyperbilirubinemia in neonates.
2. Recall the pathophysiology of bilirubin metabolism and the factors contributing to elevated bilirubin levels in newborns.
3. Identify common risk factors for developing hyperbilirubinemia.
4. Discuss potential complications of untreated hyperbilirubinemia.
5. Describe the clinical assessment and diagnostic tools used to evaluate jaundice.
6. Interpret bilirubin nomograms based on age, gestational age, and risk factors.
7. Outline nursing responsibilities in the care of neonates receiving phototherapy.
8. Demonstrate strategies for preventing complications of hyperbilirubinemia.

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What is bilirubin?

• Bilirubin is the waste product of broken-down red blood cells

• Bilirubin is then conjugated by the liver and excreted in bile

Click here if you want a quick patho review!

Review

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Overview

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An elevated Total Serum Bilirubin (TSB) level beyond the expected normal range. The normal range changes based on gestational age, day of life, and neurotoxicity risk factors

Pathological jaundice occurs within 24 hours and may indicate hemolytic disease, infection, or liver dysfunction.

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Physiological jaundice appears after 24 hours of life and resolves within a week as a normal newborn transition.

The combination of unconjugated and conjugated bilirubin; measured to determine hyperbilirubinemia

Yellowing of the skin and sclera caused by the buildup of bilirubin

Total Serum Bilirubin (TSB)

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Pathological Jaundice

Physiological Jaundice

Jaundice

Hyperbilirubinemia

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Neonatal Jaundice

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Newborns become jaundiced because:

Risk factors:

• Infants' livers are immature and have difficulty conjugating bilirubin after birth
• Larger red blood cell mass and increased red blood cell turnover (so more bilirubin)
• Decreased excretion

• Prematurity (underdeveloped liver function)
• Blood group incompatibilities between mother and baby (causes hemolysis, which increases TSB)
• Genetic conditions (especially G6PD deficiency)
• Breastfeeding (decreased volume in first few days when mother's milk is coming in affects bilirubin metabolism)

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What is the risk of untreated hyperbilirubinemia?

• High levels of unconjugated bilirubin can cross the blood brain barrier and cause a kind of brain damage called kernicterus (or bilirubin encephalopathy)

• Kernicterus is a permanent and disabling neurologic condition that can lead to:
• Cerebral palsy
• Hearing loss
• Developmental delays
• Seizure disorders
• And more

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Clinical Assessment

Infants with hyperbilirubinemia may present with:

• Jaundice
• Poor feeding
• Lethargic or jittery

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Knowledge Check #1

Treatment for Hyperbilirubinemia

Phototherapy and feeding!

Phototherapy uses UV light to break down unconjugated bilirubin to a water-soluble (conjugated) form that can be excreted (pooped out) The best way to reduce bilirubin levels is to have the baby under phototherapy lights and to support feeding to increase pooping! If severe, or phototherapy is ineffective, may require an exchange transfusion, which removes the infant's blood and replaces it with reconstituted blood at an ordered hematocrit level.

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Determining Treatment

Nomograms 101

A bilirubin nomogram plots total serum bilirubin (TSB) levels against age in hours to assess the risk of severe hyperbilirubinemia. It helps determine whether a newborn needs phototherapy, exchange transfusion, or just routine monitoring. It is available to view in Epic.

There are a few different nomograms:

• Phototherapy thresholds with no neurotoxicity risk factors
• Phototherapy thresholds with one or more neurotoxicity risk factors
• Escalation of care
• Exchange transfusion

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Neurotoxicity Risk Factors

Any of the following risk factors increases the infant's risk of neurotoxicity due to hyperbilirubinemia - these patients may have a lower threshold to initiate treatment to prevent neurological damage

• Gestational age <38 weeks and this risk increases with the degree of prematurity
• Albumin <3 g/dL
• Isoimmune hemolytic disease, G6PD deficiency, or other hemolytic conditions
• Sepsis
• Significant clinical instability in the previous 24 hours

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Nomogram Good News

It is NOT the RN's role to determine when a patient meets criteria for phototherapy, escalation of care, or an exchange transfusion - but it IS important to know there is a standardized way the providers are making this decision. There's also a website (BiliTool) that makes this easy to graph, you can play with it here if you want!

Link

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Phototherapy Basics at CHCO

• The standard for phototherapy at CHCO should be ordered as "high intensity phototherapy"
• Therapy is most effective when most of the infant's body surface is exposed!
• Keep the infant undressed except a diaper and eye protection (otherwise corneal injury can occur)
• Monitor the infant's temperature closely!
• No lotions, creams, or oils on the exposed skin - they can lead to burns from the lights!
• Diaper cream/barrier protection is still required per the Skin Care policy

• Support feeding and hydration to aid in bilirubin elimination
• Check TSB as ordered

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Initiating Phototherapy

• Your order will tell you what equipment will be needed for your patient:
• Bili blanket
• Bili pad cover
• Bili pad nest
• Single bank (1 overhead light)
• Double bank (2 overhead lights)
• Equipment needed regardless of orders:
• Eye covers
• Bilimeter

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Bili Blankets

• A bili blanket is used to provide phototherapy to posterior surfaces and allows for phototherapy to continue during feeds/while held
• Plug bili blanket in for 6-10 minutes prior to testing irradiance with bilimeter
• Check levels with the bilimeter at the numbered dots before putting on white cover/pad
• For large pads (9 spots/dots)- ensure levels average at least 49
• For small pads (6 spots/dots)- ensure levels average at least 70

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Bilimeter

Bili Blankets Cont.

• Cover the bili blanket with the pad
• The thick side of the pad goes on the side of the blanket with the baby graphic
• Use the bili pad nest to "swaddle" the infant to provide a bit more warmth and comfort
• Ensure the side of the blanket with the baby graphic is facing the infant

Bili pad nest

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Bili Lights/Giraffe Lights

• May take 6-10 minutes once plugged in and turned on to achieve light intensity
• Turn on bilimeter prior to placing under light then hold at the level of the infant. Use bilimeter at initiation and once a shift!
• Ensure irradiance level is at least 30
• Always keep light 38cm above the baby
• Too far away and the baby will not receive enough phototherapy
• Too close and you risk burning the baby!
• Measure each time baby is placed back in crib or if the lamp gets bumped!

Bili light or "giraffe light"

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Thermoregulation

• As of now, infants on Level 8 will not be in a warmer while receiving phototherapy
• The infant must be only clothed in a diaper and eye protection to maximize skin under the lights
• To keep the infant warm, consider turning up the temperature in the room. Collaborate with providers to determine if a hat will interfere with phototherapy.
• The normal temperature for an infant is 36.5 - 37.5 C
• Closely monitor the patient's axillary temperature

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Cold Stress

• Infants are at risk of cold stress and low blood glucoses!
• Signs of cold stress:
• Pale or cool skin with mottled appearance
• Acrocyanosis (blue hands and feet)
• Decreased activity/lethargy
• Weak cry
• Poor feeding
• Irritability/restlessness
• Respiratory distress
• If any of the above signs (or anything else that's concerning), check a temperature and/or a blood glucose!

If the patient cannot maintain his or her temperature in an open crib, they may need to be considered for escalation of care!

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Feeding and Fluid Status

• Breastfeeding fewer than 8 times in a 24-hour period is associated with higher TSB levels
• If a parent is lactating, offer lactation support (and place a lactation consult)
• RN or lactation consultant should observe feed to ensure proper technique (more education on this to come in Skills Days!)
• Encourage breastfeeding and/or formula feeding at least every 3 hours
• Unless otherwise ordered, infants under phototherapy may have a 30-minute break from lights each feed to encourage breastfeeding, skin-to-skin, and caregiver connection
• Turn off lights and uncover patient's eyes during feedings
• If phototherapy cannot be interrupted, feed the infant with a bottle while under the lights
• Monitor for dehydration:
• Urine output
• Moist mucous membranes
• Newborns don't have tears, so don't rely on that!
• Notify provider for any signs of dehydration, may consider supplementation

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Eye Protection

Eye protection is needed to prevent light-induced damage to the retinas, which can lead to long-term vision problems.Unless otherwise ordered, infants can take a break from the bili lights for up to 30 minutes at each feeding, in which case the lights are turned off and the eye protection is removed. Hot tip: if the eye patches aren't staying on with the provided adhesive stickers, you can use Wigglepads (from the heated high flow cannulas, obtained in the respiratory supply area) to keep them attached!

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Monitor TSB

• Obtain serum bilirubin as ordered
• When obtaining the sample, turn the phototherapy lights off or push to one side while drawing the level. Otherwise, the lights will falsely lower the bilirubin in the sample
• Use heat for heel pokes and use outer area portion of heels to poke:

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Family Support

• Babies receiving phototherapy can be very irritable, which can understandably be emotional for caregivers. They can't be swaddled or held as much as families would like.
• What can we do to help?
• Education that the most time under the lights will decrease the amount of time they need to be admitted
• Encourage caregivers to be nearby and interact with baby by talking, singing, or light touch
• Utilize the 30 minutes around each meal for skin-to-skin and other interactions
• Encourage caregivers to take breaks and/or utilize the Family Resource Center

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Documentation

Although transcutaneous bili reading is listed as an option for documentation, these are no longer used after a patient has started phototherapy - you can hide this row! Document the bilimeter reading at least once per shift, and the rest of the rows at least every 4 hours or with cares

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Risks of Phototherapy

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Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.

Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.

Use this side of the card to provide more information about a topic. Focus on one concept. Make learning and communication more efficient.

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Loose Stools

Skin Rashes

Imbalances in Fluid Status

Redness, dryness, itching, burns, and blisters can occur - ensure the lights are far enough away to still provide irradiance of at least 30 but not too close to burn

Corneal Injury

Temperature Instability

As bilirubin is broken down and removed from the body, stooling can be increased and more watery - another reason to monitor fluid status!

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If eye protection isn't used, the infant's eyes can be irreparably damaged.

The lights can increase insensible fluid loss, so close monitoring and feeding is needed

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Because the babies must be uncovered, pay close attention to their temps!

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Next Steps

You're finishing this portion of this quarter's COTF - you must also complete a skills check-off. You must complete the QR code at the end of this activity before attending the skills check-off.

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Pre-Work Completed!

You must complete this forms survey before you attend your in-person skill check-off you will not be allowed to complete your check-off without the completed survey

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Bilirubin Pathophysiology

Review

1. Red Blood Cell Breakdown: When red blood cells reach the end of their lifespan (about 120 days), they are broken down.
2. Heme to Bilirubin: The breakdown of these cells releases heme, which is then converted into bilirubin through a series of enzymatic steps.
3. Liver Processing: The water-insoluble bilirubin is transported by the blood to the liver, bound to a protein called albumin.
4. Conjugation: In the liver, bilirubin is made water-soluble by a process called conjugation, which involves attaching a substance called glucuronic acid.
5. Bile Excretion: The conjugated, or direct, bilirubin is then secreted into the bile and eliminated from the body through the digestive system.