1. An infant with yellowish skin
Case Discussion
An infant with yellowish skin
Presenter: intern 傅蓓安
Date: 2016/03/31

2. Basic Information Chief complaint Name: 許O涓之女 Chart No.: 1771XXXX
Age: 1 day old
Date of admission: 2016/07/29
Chief complaint
Dyspnea at birth

3. No maternal comorbidities prenatal care uneventful
07/29
07:47
Born to a 19-year-old mother G1P1, GA 36+3, PPROM, NSD Apgar score 9  10
BBW 2272gm(10-25 percentile) BH 46.2 cm(25-50 percentile) HC 30.5 cm(<10 percentile)
No maternal comorbidities prenatal care uneventful
Subcostal retraction, tachypnea  PEEP with neopuff  O2 3-5L/min, SpO2 >90%

4. Physical Examination Conjunctiva not pale, sclera anicteric
Neck: no jugular vein engorgement
Chest: Symmetric expansion, bilateral clear breathing sound, crackles(-), wheezing (-)
Heart: regular heart beat, murmur(-)
Extremities: no pitting edema, no cyanosis

5. Family History

6. Lab
9~30
13.5~22.0
98~118
150~350
CRP: 7.3 mg/L

7. CXR (AP)
Impression:
respiratory distress syndrome, grade I

8. Tentative diagnosis Respiratory distress syndrome, grade I A+P
Micro-lab f/u
Bubble CPAP
Empirical antibiotics: ampicillin+gentamycin

9. AST/ALT 48/10 albumin 3.5 (B/A ratio 5.4) Ca 8.4, K 3.1 LD 706
07/29
(05:30) Bilirubin (direct/total): 0.2/18.9  3 lamps of phototherapy + IVF  transferred to NICU at 07: gave 5 lamps of phototherapy etiology survey bilirubin f/u Q4H
AST/ALT 48/10 albumin 3.5 (B/A ratio 5.4) Ca 8.4, K 3.1 LD 706
07/30 morning
Bilirubin (direct/total): (09:06)1.6/18.1  (13:05) 18.6

10. Pediatrics 114.1 (2004): 297.

11. Keep intensive phototherapy
07/29
Blood exchange transfusion(BET) - pre-BET survey finished - umbilical vein CVC inserted - umbilical artery CVC failed  peripheral arterial line - brain echo: no IVH - transfusion: 15:30-17: ml/cycle, 3min/cycle, 38 cycles
07/30 morning
07/30
14:30
Bilirubin (direct/total) f/u 1hr: 0.4/13.9 4hr: 1.0/ hr: 1.1/13.0
Keep intensive phototherapy

12. Bilirubin level lowering: (07/31) 13.5  (08/02) 10.6
07/29
Bilirubin level lowering: (07/31) 13.5  (08/02) 10.6
07/30 morning
HDN investigation: - baby: type A, Rh +, direct Coomb’s test (+, trace), Ab screening test (-) - mother: type O, Rh +, direct Coomb’s test (-)
07/30
14:30
07/31
-08/02
G6PD 24.1 U/g Hb ( )
Blood culture: negtive
HSV IgM & IgG(-), toxoplasma IgG(-) CMV(-), RPR/VDRL(-)
Transferred to level II on 08/02

13. Bilirubin level lowering
07/29
07/30 morning
07/30
14:30
Bilirubin level lowering
Hyperkalemia: (08/03) 7.02  6.5  5.9 (08/04) 6.92  6.32
With +~++ hemolysis
EKG: normal
keep bricanyl 0.2amp Q6H
08/01
-08/02
08/03
-08/05

14. Persistent hyperkalemia Persistent +~++ hemolysis
07/29
07/30 morning
07/30
14:30
08/01
-08/02
08/03
-08/05
Persistent hyperkalemia
Persistent +~++ hemolysis
(08/08) micro K 5.84, bil-T 8.7
MBD on 08/08
08/06
-08/08

15. Discussion
blood exchange transfusion

16. Pediatrics 114.1 (2004): 297.

17. If TSB level meets the transfusion level or TSB ≧ 25mg/dL
or TSB≧ 20mg/dL in sick or GA<38 infant
Request blood for possible exchange transfusion
Intensive phototherapy
If infant with isoimmune hemolytic diseases, and (1) TSB rise despite phototherapy
(2) Within 2-3mg/dL of exchange level
IVIG 0.5-1g/kg over 2hr, repeat in 12hr if necessary

18. If TSB
(1)not decreasing
(2)Moving toward exchange transfusion level
(3)B/A ratio high
Blood exchange transfusion

19. Double volumn BET + continue phototherapy
Intensive phototherapy
Prepare for BET
ABE
STB in
Exchange
zone
STB↓
in 3-4hr
STB>25 PT
AAP’s
guideline
STB in
PT zone
Intensive
phototherapy
STB<2mg
Of exchange
STB below
PT zone
STB f/u
After 12hr
Seminars in perinatology, Vol. 35, No. 3, pp

20. Blood exchange transfusion
Remove circulating antibody coated red blood cells and hemolytic products
Wash out unconjugated bilirubin
Provide fresh donor albumin with Bilirubin binding site

21. Choice and use of donor blood
Cross-matched
“fresh” (< 5days) to avoid hyperkalemia
pRBC:FFP=3:1, FFP from AB blood type
Saline wash, irradiation, warmed

22. Umbilical arteries & vein Peripheral vessels
Umbilical arteries & vein
Peripheral vessels

23. Peripheral vessels access
Pros: temperature regulation, less GI complication, could applied in any stage
Cons: local limb ischemia, tendency of occlusion
Pediatrics 2008;122;e905

24. Volumn & Rate
Estimated blood volumn: 80-90ml/kg - SVBET: exchange 63% of blood - DVBET: exchange 86% of blood
Bilirubin removed was 45% higher than the fall in serum bilirubin
Body weight
ml/cycle
<1500gm
5ml
1500~2500gm
10ml gm
15ml
>3500gm
20ml

25. Adverse events
Mortality rate: % - necrotizing enterocolitis - cardiovascular collapse - sepsis
Adverse event rate: 6.7% mostly resolve in 48hr
100ml blood + 1ml calcium gluconate
[1]J Pediatr 2004;144:626-31; [2] Pediatrics 1997;99;e7

26. Thank You!