Chapter 70

• • Prevent neurotoxicity induced by hyperbilirubinemia.

• Jaundice and intermediate to advanced stages of acute bilirubin encephalopathy are present even if the serum bilirubin level does not exactly fit the guidelines.

• • Early phase: Severely jaundiced infants become lethargic, hypotonic, and feed poorly.

• Intermediate phase: Moderate stupor; irritability; and hypertonia, manifested by backward arching of the neck (retrocollis) and trunk (opisthotonos); fever; and high-pitched cry that may alternate with drowsiness.

• Treat coagulopathy due to disseminated intravascular coagulation and life-threatening metabolic disorders.

• Correct polycythemia using a partial exchange transfusion, meaning that < 1 blood volume is removed and then replaced with normal saline.

• Treat severe anemia associated with heart failure with partial exchange transfusion, using packed red blood cells as the replacement solution.

• Recommended after intensive phototherapy fails.

• • Quantifying the risks of morbidity and mortality accurately is difficult because exchange transfusions are now rarely performed.

• Death has been reported in approximately 0.3% of all procedures; although in otherwise well term and near-term infants (> 35 weeks’ gestation), the risk is probably much lower.

• Significant morbidity occurs in as many as 5% of cases.

• • Infection.

• Complications of vascular catheters (vasospasm, thrombosis).

• Necrotizing enterocolitis.

• The risks associated with the use of blood products must always be considered.

• Hypoxic-ischemic encephalopathy and AIDS have been reported in otherwise healthy infants receiving exchange transfusions.

• • In general, phototherapy is initiated at lower TSB levels in an attempt to avoid exchange transfusion.

• Additional risk factors for neurotoxicity, such as prematurity, sepsis, and acidosis, should be carefully considered when deciding whether to proceed with an exchange transfusion.

• Intravenous gamma-globulin has been shown to reduce the need for exchange transfusions in Rh and ABO hemolytic disease.

• Therefore, in isoimmune hemolytic disease, administration of intravenous gamma-globulin (0.5–1 g/kg over 2 hours) is recommended.

• • If the TSB is rising despite intensive phototherapy.

• If the TSB level is within 2–3 mg/dL of the exchange level.

• The fluid volume required to administer the dose of gamma-globulin is considerable and needs to be factored into its use for critically ill newborns.

 • While there are multiple causes of hyperbilirubinemia, severe disease is most commonly the result of isoimmune hemolytic disease of the newborn secondary to Rh, ABO, or other antigen incompatibility.• Perhaps the most difficult aspect of this procedure is determining when the level of hyperbilirubinemia warrants its use.   • A clinical practice guideline was recently published by the American Academy of Pediatrics Subcommittee on Hyperbilirubinemia.   • Recommended total serum bilirubin (TSB) levels for exchange transfusion are provided in this document and are based largely on keeping TSB levels below those at which kernicterus has been reported.• Exchange transfusion is performed infrequently due to improved prenatal prevention and management of hemolytic disease of the newborn.

• • The possible need for exchange transfusion should be discussed with the family at the onset ...

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