Hyperbilirubinemia – Newborn Complications (Nursing)

by Jacquelyn McMillian-Bohler

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    00:01 Now, let's talk about the next newborn complication.

    00:04 Hyperbilirubinemia.

    00:06 First, I want you to say that three times fast.

    00:09 Okay now I'll tell you what it is.

    00:11 Hyperbilirubinemia is the buildup of excess biulirubin in the baby's blood.

    00:17 Let's talk about the physiology.

    00:20 So in the case of hyperbilirubinemia, what's going on is that red blood cells have to be broken down.

    00:26 Where do all these extra red blood cells come from? Here's a list.

    00:30 First of all, any type of birth trauma that might lead to bruising.

    00:35 So perhaps there was an instrument delivery or some other traumatic event.

    00:39 We talked about cephalohematoma in our lecture on newborn assessment.

    00:43 Remember, there's a buildup of blood.

    00:45 Extra red blood cells.

    00:47 There can also be physiologic destruction of RBCs that happen just as a part of normal transition.

    00:53 We can also have pathologic destruction, meaning that something has gone wrong, In this case of sensitization, or blood incompatibilities might be a number one cause.

    01:04 Either way, any of these conditions can lead to the need for a breakdown of excessive red blood cells.

    01:11 In order for all of those extra red blood cells to be excreted from the body, it has to be conjugated bilirubin.

    01:18 So let's talk about how we get there.

    01:20 So from hemolysis of the RBCs, we get unconjugated bilirubin.

    01:25 And that unconjugated bilirubin has to be conjugated.

    01:29 It has to be bound in order to leave the body.

    01:32 So at the serum albumin binding sites, the unconjugated bilirubin can bind to the albumin.

    01:40 However, in order for all those RBCs to be excreted from the body, it has to leave the body as conjugated bilirubin.

    01:49 So let's talk about how we get there.

    01:51 As the red blood cells are broken down, they are broken down into unconjugated bilirubin.

    01:56 That's allowed to float freely in the bloodstream.

    02:00 Now, there are serum albumin sites.

    02:02 And in the serum albumin sites, the unconjugated bilirubin can be bound.

    02:07 However, if there are more RBCs than there are albumin binding sites, there's going to be an excessive amount of bilirubin allowed to float into the bloodstream.

    02:16 When that happens, we get staining of the skin.

    02:20 The cutaneous tissue, which gives us that yellow jaundice color.

    02:24 Over time, in an excessive amount of bilirubin, we can also have staining of brain tissue that can lead to kernicterus and brain damage.

    02:33 The bilirubin that's bound to the albumin is then transferred to the liver where it is conjugated.

    02:39 It becomes conjugated bilirubin.

    02:42 And the bile helps to transport that conjugated bilirubin to the intestines, and it's able to be excreted both in the stool and in the urine.

    02:52 And that's how we get rid of all those extra broken down red blood cells.

    02:58 That's the physiology of hyperbilirubinemia.

    03:02 Now, let's talk about the risk factors for hyperbilirubinemia.

    03:05 Interestingly, we have a mnemonic for this.

    03:08 So risk factors include: Jaundice within the first 24 hours after birth.

    03:12 This would coincide with pathologic hyperbilirubinemia.

    03:17 Sometimes after 24 hours, especially with babies that are breastfed, they may experience physiologic jaundice, which is not as problematic.

    03:26 But jaundice within the first 24 hours is always pathologic and will always need further workup.

    03:32 A - A sibling who was jaundiced as a neonate.

    03:36 So a family history of hyperbilirubinemia.

    03:39 U - Unrecognized hemolysis such as ABO incompatibility.

    03:43 Remember my chart across the top.

    03:46 N - Nonoptimal sucking or nursing.

    03:49 So in this case, think about anything that's going to get in the way of excreting the bilirubin.

    03:54 So if you're not getting enough in, then you're not going to have anything coming out.

    03:58 D - A deficiency in glucose-6 - phosphate dehydrogenase.

    04:02 This is a genetic disorder.

    04:04 And infection. Remember one system off another system off.

    04:09 C - Cephalohematoma or bruising.

    04:12 Chart across the top as a cause for extra RBC production.

    04:16 Or E - East Asian or Mediterranean descent.

    04:19 Just because there may be an increased risk for any type of anemia, and that can cause a need for an increased amount of red blood cells.

    04:26 So there's your mnemonic for your risk factors for hyperbilirubinemia.

    04:31 Let's talk about treatment for hyperbilirubinemia.

    04:34 Now you might notice this baby is under some pretty cool blue lights.

    04:38 This is not a special effect.

    04:39 These are Bili lights also known as phototherapy.

    04:42 This is going to help increase the binding of that bilirubin.

    04:46 So one of the things we want to notice is that the baby's not really wearing any clothes.

    04:51 Well, that's to allow more of the light to come in contact with the skin, which is what we want.

    04:55 But we also want to make sure the baby doesn't get too cold or too hot.

    05:00 So depending how the phototherapy is delivered, whether it's in an isolette or over a radiant warmer, or maybe a blanket will determine, what other things we need to do to make sure the baby maintains temperature, So remember, it could be too hot or too cold, so check both.

    05:16 I and O is going to be super important for babies that are experiencing hyperbilirubinemia.

    05:21 Remember, the way we excrete the conjugated bilirubin is through the stool and the urine.

    05:26 So it's important that the baby eats.

    05:28 Well, because that's how they drink too.

    05:31 Also making sure the baby's eyes are protected from the lights.

    05:35 We don't want to cause eye damage from phototherapy.

    05:38 So the cool sunglasses are not just cool, they're actually functional.

    05:43 And finally, remember, thinking about how this bilirubin is excreted - through the urine and through the feces, and we want more of it.

    05:50 So we want to make sure that the baby stays dry and that our skin integrity remains intact throughout this entire process.

    05:59 When we talk about preventing hyperbilirubinemia, we want to go back to the things we've already been talking about.

    06:05 Maintaining a thermoneutral environment.

    06:08 So watching out for those four ways that the baby can lose heat and making sure that their temperature remains normal is one way we can prevent hyperbilirubinemia.

    06:17 Also making sure the baby stays well fed.

    06:20 So early and frequent feedings regardless of the method.

    06:24 Checking input and output for any baby is going to be really important.

    06:28 But this is definitely effective for preventing hyperbilirubinemia.

    06:33 Also a skin into a skin assessment.

    06:36 Making sure that we notice any signs of jaundice.

    06:39 Remember, if the jaundice happens within the first 24 hours, that's pathologic jaundice.

    06:44 If it happens after 24 hours, it may be physiologic jaundice.

    06:50 To provide a more objective measurement of the bilirubin levels, we can use what's called a transcutaneous bilimeter.

    06:57 Once we have that value, then we can use that information to determine whether feeding is appropriate, bili lights are appropriate, or whether we have to have an exchange of the red blood cells.

    About the Lecture

    The lecture Hyperbilirubinemia – Newborn Complications (Nursing) by Jacquelyn McMillian-Bohler is from the course Newborn Complications (Nursing).

    Included Quiz Questions

    1. Colic
    2. Bruising
    3. Pathologic destruction
    4. Cephalohematoma
    1. A parent that was jaundiced as a neonate
    2. A sibling that was jaundiced as a neonate
    3. Unrecognized hemolysis in mother
    4. Non-optimal sucking/nursing
    1. Temperature
    2. Intake and output
    3. Skin
    4. Eyes
    5. Abdomen
    1. Transcutaneous bilimeter
    2. Centrifuge
    3. TENS machine
    4. TCOM

    Author of lecture Hyperbilirubinemia – Newborn Complications (Nursing)

     Jacquelyn McMillian-Bohler

    Jacquelyn McMillian-Bohler

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