Hijo de Sonia Marlene Sanchez HC 1043672mat 1059646 Hijo

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Hijo de Sonia Marlene SanchezHC 1043672-mat-
1059646 Hijo

• FI 19-06-03 (14.23)
• FE20-06-03
• Embarazo de 35 sem en madre de 37 años,con
  ruptura prematura de membranas.
• 8 controles prenatales normales.
• Grupo sanguineo mat. O
• TParto y parto vaginales normales.

• RN AT, Masculino APGAR 9-10/10
• No tiene clasif . Materna en hoja RN.
• Peso 2.520 gm, Talla 47 cm PC 32 cm
• RN sano incomp. OA
• Ictericia precoz, solic. Bilirrubinas
• Hc 49, hb16, ret. 4.5 BI5.5, BD0,
• Salida rec. Sol
• Control CE
• A
• Cooms dir neg
• Bilirr ind 9.1 mg /dl (20-06-03) a las 11.54

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Hijo de Sonia Marlene SanchezHC 1043672-mat-
1059646 Hijo

• Ingresa a Urgencias
• 26-06-03 (15,15)
• Ictericia III, 2.4 kg,
• Toman BD. 27 mg, BT 29 mg/dl, Se inicia
  fototerapia.Ex Fisico Activo, succión busqueda.
• SS autorización Exanguinotransfusión.

• 27-06-03 Valoración por docente no considera
  exanguino.
• BI 15mgfototerapia.
• Salida 29-06-03

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• Brief Summary
• GUIDELINE TITLE
• Practice parameter management of
  hyperbilirubinemia in the healthy term newborn.
• BIBLIOGRAPHIC SOURCE(S)
• American Academy of Pediatrics. Practice
  parameter management of hyperbilirubinemia in
  the healthy term newborn. Provisional Committee
  for Quality Improvement and Subcommittee on
  Hyperbilirubinemia. Pediatrics 1994 Oct94(4 Pt
  1)558-65. 31 references
• ADAPTATION
• Not applicable Guideline was not adapted from
  another source.
• DATE RELEASED
• 1994 Oct (reviewed 2000)

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• MAJOR RECOMMENDATIONS
• Evaluation
• Maternal prenatal testing should include ABO and
  Rh(D) typing and a serum screen for unusual
  isoimmune antibodies.
• A direct Coombs' test, a blood type, and an Rh(D)
  type on the infant's (cord) blood are recommended
  when the mother has not had prenatal blood
  grouping or is Rh-negative.
• Institutions are encouraged to save cord blood
  for future testing, particularly when the
  mother's blood type is group O. Appropriate
  testing may then be performed as needed.
• When family history, ethnic or geographic origin,
  or the timing of the appearance of jaundice
  suggests the possibility of glucose-6-phosphate
  dehydrogenase deficiency or some other cause of
  hemolytic disease, appropriate laboratory
  assessment of the infant should be performed.
• Total serum bilirubin level needs to be
  determined in infants noted to be jaundiced in
  the first 24 hours of life.
• In newborn infants, jaundice can be detected by
  blanching the skin with digital pressure,
  revealing the underlying color of the skin and
  subcutaneous tissue. The clinical assessment of
  jaundice must be done in a well-lighted room.
  Dermal icterus is seen first in the face and
  progresses caudally to the trunk and extremities.
  As the TSB level rises, the extent of
  cephalocaudad progression may be helpful in
  quantifying the degree of jaundice use of an
  icterometer or transcutaneous jaundice meter may
  also be helpful.
• Evaluation of newborn infants who develop
  abnormal signs such as feeding difficulty,
  behavior changes, apnea, or temperature
  instability is recommendedregardless of whether
  jaundice has been detectedto rule out underlying
  illness.

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• Follow-up should be provided to all neonates
  discharged less than 48 hours after birth by a
  health care professional in an office, clinic, or
  at home within 2 to 3 days of discharge.
• A report of dark urine or light stools should
  prompt a measurement of direct serum bilirubin.
  If the history (particularly the appearance of
  the urine and stool) and physical examination
  results are normal, continued observation is
  appropriate. If jaundice persists beyond 3 weeks,
  a urine sample should be tested for bilirubin,
  and a measurement of total and direct serum
  bilirubin obtained.

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• Treatment
• Jaundice occurring before age 24 hours is
  generally considered "pathologic" and requires
  further evaluation. Although some healthy infants
  appear slightly jaundiced by 24 hours, the
  presence of jaundice before 24 hours requires (at
  least) a serum bilirubin measurement and, if
  indicated, further evaluation for possible
  hemolytic disease or other diagnoses.
  Phototherapy and/or exchange transfusion may be
  indicated for rapidly rising total serum
  bilirubin levels in the first 24 hours of life.
• For the treatment of the 25- to 48-hour-old
  infant, phototherapy may be considered when the
  TSB level is gt12 mg/dL (210 µmol/L). Phototherapy
  should be implemented when the TSB level is gt15
  mg/dL (260 µmol/L). If intensive phototherapy
  fails to lower a TSB level of gt20 mg/dL (340
  µmol/L), exchange transfusion is recommended. If
  the TSB level is gt25 mg/dL (430 µmol/L) when the
  infant is first seen, intensive phototherapy is
  recommended while preparations are made for an
  exchange transfusion. If intensive phototherapy
  fails to lower the TSB level, exchange
  transfusion is recommended. The higher TSB levels
  in a 25- to 48-hour-old infant suggest that the
  infant may not be healthy and indicate the need
  for investigation into the cause of
  hyperbilirubinemia, such as hemolytic disease.

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• Phototherapy may be considered for the 49- to
  72-hour-old jaundiced infant when the TSB level
  is gt15 mg/dL (260 µmol/L). Phototherapy is
  recommended when the TSB level reaches 18 mg/dL
  (310 µmol/L). If intensive phototherapy fails to
  lower the TSB level when it reaches or is
  predicted to reach 25 mg/dL (430 µmol/L), an
  exchange transfusion is recommended. If the TSB
  level is gt30 mg/dL (510 µmol/L) when the infant
  is first seen, intensive phototherapy is
  recommended while preparations are made for
  exchange transfusion. If intensive phototherapy
  fails to lower the TSB level, an exchange
  transfusion is recommended.
• For the infant gt72 hours old, phototherapy may be
  considered if the TSB level reaches 17 mg/dL (290
  µmol/L). Phototherapy needs to be implemented at
  a TSB level of gt20 mg/dL (340 µmol/L). If
  intensive phototherapy fails to lower a TSB level
  of gt25 mg/dL (430 µmol/L), exchange transfusion
  is recommended. If the TSB level is gt30 mg/dL
  (510 µmol/L) when the infant is first seen,
  intensive phototherapy is recommended while
  preparations are made for an exchange
  transfusion. If intensive phototherapy fails to
  lower the TSB level, an exchange transfusion is
  recommended.

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• Treatment of Jaundice Associated with
  Breast-feeding in the Health Term Newborn
• The AAP discourages the interruption of
  breast-feeding in healthy term newborns and
  encourages continued and frequent breast-feeding
  (at least eight to tem times every 24 hours).
  Supplementing nursing with water or dextrose
  water does not lower the bilirubin level in
  jaundiced, health, breast-feeding infants.
  Depending on the mother's preference and the
  physician's judgment, however, a variety of
  options are available for possible implementation
  beyond observation, including supplementation of
  breast-feeding with formula or the temporary
  interruption of breast-feeding with formula,
  either of which can be accompanied by
  phototherapy.

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• DEVELOPER(S)
• American Academy of Pediatrics
• GUIDELINE COMMITTEE
• Provisional Committee on Quality Improvement
• Subcommittee on Hyperbilirubinemia

10
Cochrane Collaboration was used including
searches of the Cochrane Controlled Trials
Register, MEDLINE, EMBASE and discussion with
experts in the field.

• In the first week of life approximately 50 of
  newborn infants have clinically detectable
  jaundice (Maisels 1982). The majority of these
  infants have no underlying disease and their
  jaundice results from the increased bilirubin
  production and decreased excretion which are
  normally seen in the newborn period
  (physiological jaundice). In a minority, jaundice
  indicates a more serious underlying pathology
  such as haemolysis, septicaemia or metabolic
  disease (non-physiological jaundice). Elevated
  serum bilirubin (SBR) can damage neurones, and
  for this reason it is measured in a newborn
  infant with obvious jaundice or signs of
  underlying disease.

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• Since the early 1970's neonatal jaundice has been
  treated with phototherapy. Phototherapy causes
  photoisomerisation of bilirubin into a
  water-soluble form which can be excreted by the
  kidney. It effectively decreases the SBR in
  jaundiced newborn infants and decreases the need
  for exchange blood transfusion (Maisels 1992). To
  deliver phototherapy the infant is nursed under
  halogen or fluorescent lamps and the eyes are
  covered with a mask to prevent retinal damage.
  The disadvantages of delivering phototherapy in
  this way are that it can interfere with
  parent-child bonding (Fetus Newborn 1986), and
  that a displaced eye mask can cause nasal
  obstruction (Al-Salihi 1975). However, this
  method of delivering phototherapy (conventional
  phototherapy) remains widely used.

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• Root causes identified Examination of the recent
  cases has identified a pattern of root causes
  related to four patient care processes 
• Patient assessment
• The unreliability of the visual assessment of
  jaundice in newborns with dark skin.
• Failure to recognize jaundice in an infant--or
  its severity--based on visual assessment, and
  measure a bilirubin level before the infant's
  discharge from the hospital or during a follow-up
  visit.
• Failure to measure the bilirubin level in an
  infant who is jaundiced in the first 24 hours.
• Continuum of care
• Early discharge (before 48 hours) with no
  follow-up within one to two days of discharge.
  This is particularly important for infants less
  than 38 weeks of gestation.
• Failure to provide early follow-up with physical
  assessment for infants who are jaundiced before
  discharge.
• Failure to provide ongoing lactation support to
  ensure adequacy of intake for breast-fed
  newborns. 

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Inadecuado MAL HECHO BIEN HECHO

• Manejo de Hiperbilirrubinemia inadecuado en las
  primeras 24 h.
• No esta estudiada la hiperbilirrubinemia s/ guias
• Manejo inadecuado de Hiperbilirrubinemia al 7 dia
  con niveles de 29 mg
• No tiene valoración neurologica en la HC
• No hay firma de docente responsable

• FOTOTERAPIA TARDIA
• BILIRRUBINAS MAL INTERPRETADAS

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Adecuado bien hecho mal hecho

• Bilirrubinas tomadas en las primeras 24 horas

• Fototerapia tardia
• Examen neurologico

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• Patient and family education
• Failure to provide appropriate information to
  parents about jaundice and failure to respond
  appropriately to parental concerns about a
  jaundiced newborn, poor feeding, lactation
  difficulties and change in newborn behavior and
  activity.
• Treatment
• Failure to recognize, address or treat rapidly
  rising bilirubin.
• Failure to aggressively treat severe
  hyperbilirubinemia in a timely manner with
  intensive phototherapy or exchange transfusion