Management - Other Tx
Management
Treatment
Other
Double-volume (160-170 cc/kg) exchange transfusion will replace approximately 85% of the circulating RBCs and reduce the serum bilirubin by about 50%. It should be done using aliquots of about 10% of the infant's blood volume and usually takes about an hour. Discussion of the technique of exchange transfusion is beyond the scope of this lecture. The complications of an exchange are well documented. The AAP Guidelines specifically state that an exchange transfusion "should be performed only by trained personnel in an NICU with full monitoring and resuscitation capabilities."There is no evidence that excess fluid administration lowers serum bilirubins. Treatment of dehydration, of course, is always recommended. Also the maintenance of adequate hydration helps ensure normal urine output, bile flow and stool excretion. However, unless there is clinical evidence of dehydration, routine IV fluid or other supplementation (e.g., with dextrose water) of the term or near-term infant receiving phototherapy is not recommended.The metalloporphyrins are heme compounds in which other multivalent metals are substituted for iron. They have been shown to be potent inhibitors of heme oxygenase, leading to decreased bilirubin levels in animals. The best studied in humans is tin (Sn)-mesoporphyrin, which has a dose-dependent effect of decreasing bilirubin levels and a decreased need for phototherapy in normal human neonates, as well as those with ABO incompatibility and G6PD deficiency. These small studies have also demonstrated the photosensitizing effect of these compounds, producing various types of skin injury. Sn-mesoporphyrin is not currently approved by the FDA.Phenobarbital is a well-known inducer of hepatic microsomal enzymes. Its use has been shown to increase BUG-T levels, leading to lower serum bilirubins. However, when given to the neonate, even immediately after delivery, it is much less effective than if given to the pregnant mother for at least 2 weeks before delivery. It is also much less effective in the premature. Because of this and its potential for sedation, addiction and other metabolic effects, its use is reserved for certain ethnic groups at high risk for severe hyperbilirubinemia and patients with type 2 Crigler-Najjar syndrome.Oral administration of non-reabsorbable substances which bind bilirubin in the intestine can reduce the enterohepatic recirculation of bilirubin leading to decreased serum levels. Activated charcoal has been used but is only effective when given in the first 12 hours of life. Agar has also been tried, but neither has been well studied nor are either approved for use in the treatment of jaundiced neonates.Return to top of page