Register No: RCOG guideline. Contributes to CQC Standards No

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1 MANAGEMENT OF NEONATAL HYPERBILIRUBINIA CLINICAL GUIDELINES Register No: Status: Public Developed in response to: Contributes to CQC Standards No Intrapartum NICE Guidelines RCOG guideline C5a Consulted With Post/Committee/Group Date Clinical Directors Women, Childrens & Sexual Health Division November 2010 Bernie Rigdon Acting Head of Midwifery Services Georgina Sparrow Acting Head of Midwifery Services Deb Cobie Maternity Risk Management Sheena Smith Senior Midwife Denise Grey Lead Midwife for infant feeding Professionally Approved By Dr. Saravanan Consultant Lead for Risk Management November 2010 Mr. Spencer Clinical Director, Obstetric and Gynaecology Version Number 3.1 Issuing Directorate Maternity Services Ratified By Document Ratification Group Ratified On 27th January 2011 Trust Executive Sign Off Date CMB February 2011 Implementation Date 9th February 2011 Next Review Date January 2014 Author/Contact for Information Sharon Pilgrim, ANNP Policy to be followed by (target staff) Midwives, Obstetricians, Paediatricians and Neonatal nurses Distribution Method Intranet & Website. Notified on Staff Focus Related Trust Policies (to be read in conjunction with) Standard Infection Prevention Hand Hygiene Examination of the Newborn Guideline for Maternity Record Keeping including Documentation in Handheld Records Mandatory training policy for maternity services incorporating training needs analysis Review No Reviewed by Review Date 1.0 Julie Bishop October Sharon Pilgrim October Sharon Pilgrim January Sharon Pilgrim clarification to point 6.3 October 2012 It is the personal responsibility of the individual referring to this document to ensure that they are viewing the latest version which will always be the document on the intranet 1

2 INDEX 1. Purpose of the Guideline 2. Equality and Diversity 3. Introduction 4. Incidence and Risk factors 5. Types of Jaundice 6. Investigations and Observations 7. Phototherapy 8. Feeding and hydration 9. Exchange Transfusion 10. Other Management Strategies 11. Prolonged Neonatal Jaundice 12. Bilirubin Encephalopathy 13. Infection Prevention 14. Staff and Training 15. Audit and Monitoring 16. Communication 17. References 18. Appendices A. Appendix A - Threshold table B. Appendix B - Phototherapy Pathway C. Appendix C - Exchange transfusion Pathway D. Appendix D - Phototherapy threshold charts 2

3 1.0 Purpose of the Guideline 1.1 To ensure that infants with hyperbilirubinaemia are identified and correctly treated. 1.2 To provide management strategies for all types and levels of hyperbilirubinaemia 1.3 To minimise the incidence of complications of hyperbilirubinaemia. 2.0 Equality and Diversity 2.1 Mid Essex Hospitals Services NHS Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. 3.0 Introduction 3.1 All babies develop elevated serum bilirubin (SBR) levels to a greater or lesser degree in the first week of life. This is due to an increased production (accelerated red blood cell breakdown), a decreased removal (transient liver enzyme insufficiency) and an increased reabsorption (enterohepatic circulation). 3.2 However, when a baby does become jaundiced, a common dilemma is deciding at what SBR level to intervene. The decision is influenced by whether the baby is term or preterm, well or sick, and the presence or absence of blood factors predisposing to hyperbilirubinaemia. 4.0 Risk factors 4.1 Virtually all babies have a transient rise in SBR, but only about 50% are visibly jaundiced. Babies of Asian background having a higher incidence. 4.2 It is clinically useful to classify jaundice according to the age of the baby when he/she becomes visibly jaundiced. 4.3 Factors likely to make physiological jaundice worse in a given baby include: prematurity bruising cephalohaematoma polycythaemia delayed passage of meconium breast feeding certain ethnic groups 5.0 Types of Jaundice 5.1 Early (days 1-2), always pathological and usually due to the following: Haemolysis Rhesus isoimmunisation ABO and other blood group incompatibilities Sepsis Rarer causes of Haemolysis 3

4 Red cell enzyme defects Red cell membrane defects Hepatitis 5.2 Normal (days 3-10), very common occurrence and can be subdivided into the following: Physiological - Uncomplicated Physiological - Complicated 5.3 Late (days 14+), this jaundice can occur due to the following: Breast milk - common occurrence Conjugated jaundice - uncommon occurrence Inherited deficiency of glucuronyl transferase enzymes - very rare occurrence 6.0 Investigations and Observations 6.1 Detailed history is recorded in the postnatal/neonatal health care records highlighting the following points: Maternal blood group and antibody status Baby s blood group and direct antibody test (DAT) if available Feeding history Colour of stools/urine Neonatal vitamin K administration Onset of neonatal jaundice Antenatal history Any risks for antenatally acquired infections Family history (any history of splenectomies or severe jaundice) 6.2 Jaundice starts on the head, and extends towards the feet as the level rises. Infants are divided into 5 zones and the rise in SBR is associated with progression through the zones. (Refer to Appendix A) 6.3 Transcutaneous bilirubinometry (Biligun) can be used as an immediate screening test on infants above 35 weeks gestation who appear jaundiced after 24 hours of age. 6.5 Investigations to be undertaken if the Biligun shows a value of SBR within 50 µmol/l of the threshold for the relevant phototherapy threshold for the particular baby. 6.6 Any baby having jaundice at less than 24 hours of age should be investigated promptly. 6.7 The following investigations should be performed: Blood Group DAT Full blood count (FBC) Blood Film Reticulocyte Count Liver function test (LFT) with split serum bilirubin Urea and electrolytes Investigations for sepsis in unwell babies if clinically indicated 4

5 6.8 If in any doubt with regards to the Biligun value, the laboratory values for serum Bilirubin should be taken. 6.9 Treatment with phototherapy should be initiated while the results of the lab are awaited if the screening bilirubin value from the Biligun is near or above the threshold level for phototherapy. 7.0 Phototherapy 7.1 Use serum bilirubin measurement and the treatment thresholds in the threshold table and treatment threshold graphs when considering the use of phototherapy. 7.2 Do not use phototherapy in babies whose bilirubin does not exceed the phototherapy threshold levels in the threshold table and treatment threshold graphs 7.3 In babies with a gestational age of 38 weeks or more whose bilirubin is in the consider phototherapy category in the threshold table, repeat the bilirubin measurement in 6 hours regardless of whether or not phototherapy has subsequently started. 7.4 In babies with a gestational age of 38 weeks or more whose bilirubin is in the repeat bilirubin measurement category in the threshold table, repeat the bilirubin measurement in 6-12 hours. 7.5 Place the baby in the supine position 7.6 Give baby eye protection and routine eye care 7.7 Ensure treatment is applied to the maximum area of skin 7.8 Monitor the baby s temperature and ensure the baby is kept in a thermoneutral environment. 7.9 Monitor hydration by daily weighing of the baby and assessing wet nappies Support parents and carers and encourage them to interact with the baby Do not use white curtains routinely with phototherapy 7.12 During phototherapy: repeat serum bilirubin measurement 4 6 hours after initiating phototherapy repeat serum bilirubin measurement every 6 12 hours when the serum bilirubin level is stable or falling Stopping phototherapy Stop phototherapy once serum bilirubin has fallen to a level at least 50 micromol/litre below the phototherapy threshold (see threshold table and treatment threshold graphs. Check for rebound of significant hyperbilirubinaemia with a repeat serum bilirubin measurement hours after stopping phototherapy 5

6 8.0 Feeding and Hydration 8.1 During conventional phototherapy Encourage short breaks of up to 30minutes for breast feeding nappy changing and cuddles. Continue lactation/feeding support Do not give additional fluids. 8.2 During multiple phototherapy Do not interrupt phototherapy for feeding. Administer intravenous fluids or enteral feeds. Continue lactation support so that breast feeding can start again when treatment stops 9.0 Exchange transfusion 9.1 Use a double-volume exchange transfusion to treat babies: Whose serum bilirubin level indicates its necessity (see threshold table and treatment threshold graphs despite intensive phototherapy. Blood should be ordered as the level is approached as it may take some time to arrange. With clinical features and signs of acute bilirubin encephalopathy. If a baby is admitted with a serum Bilirubin above the exchange line, intensive phototherapy should be commenced and blood ordered for transfusion, the level should then be repeated every 2 to 3 hours and exchange performed if the level remains above the exchange level after 6 hours. If there is a known history of significant Rhesus isoimmunisation (indicated by high or rising maternal antibody levels) and the baby has not received in utero blood transfusion send cord blood sample for Hb and Bilirubin. Consider transfusion if the Hb is <10g/dl or cord blood serum bilirubin is >80 micromol/l Blood collected after exchange transfusion has no value when investigating rarer causes of hyperbilirubinaemia, therefore blood for these tests should be done before the exchange transfusion takes place. 9.2 During exchange transfusion do not: stop continuous multiple phototherapy perform a single-volume exchange use albumin priming routinely administer intravenous calcium. 9.3 Following exchange transfusion: maintain continuous multiple phototherapy measure serum bilirubin level within 2 hours and manage according to threshold table and treatment thresholds graphs 6

7 10.0 Other Management Strategies 10.1 Term and preterm babies with significant hyperbilirubinaemia in the first 28 days of life with bilirubin rising greater than 10 micromol/litre per hour or babies with co-morbid illnesses such as infections have been shown to have fewer exchange transfusions if treated with a combination of IVIG (500mg/kg over 4 hours) alongside phototherapy than those treated with phototherapy alone Indications are as follows: DAT positive who has predicted severe disease based on antenatal investigation Rising serum total bilirubin at exchange level 10.1 Use intravenous immunoglobulin (IVIG) (500 mg/kg over 4 hours) as an adjunct to continuous multiple phototherapy in cases of Rhesus haemolytic disease or ABO haemolytic disease when the serum bilirubin continues to rise by more than 8.5 micromol/litre per hour All neonates who receive IVIG need follow-up and will need FBC, Reticulocyte count and blood film after 2 weeks Prolonged Neonatal Jaundice 11.1 Prolonged jaundice is defined as jaundice lasting more than 14 days in a term baby or 21 days in a preterm baby Observe the colour of urine and stools 11.3 Carry out a full blood count, blood group and DAT test and a urine culture 11.4 Perform a full metabolic screen Consult expert advice for babies with a conjugated bilirubin level greater than 25 micromol/litre Bilirubin Encephalopathy 12.1 Unconjugated bilirubin is toxic to brain cells; the mildest form of bilirubin toxicity is sensorineural hearing loss. Severe jaundice requiring exchange transfusion (criterion was bilirubin > 340 micromol/litre) and early onset of jaundice (within 24 hours) are statistically significant risk factors for hearing loss Risk factors for bilirubin encephalopathy are as follows: Lower gestation Hypoxia Asphyxia Acidosis Infection Hypothermia Decreased albumin binding (low levels or drug interference i.e. ceftriaxone) 12.3 Signs of acute bilirubin encephalopathy are as follows: Early signs: Lethargy, Hypotonia, Poor feeding Unstable temperature 7

8 Arching of head neck and back (opisthotonia) Spasticity Seizures 12.4 Severe bilirubin toxicity causes Kernicterus which is characterised by death of brain cells and yellow staining of the grey matter specially the basal ganglia. In the acute stage this presents as encephalopathy and is associated with late sequelae of athtoid cerebral palsy 12.5 Babies are at increased risk of developing Kernicterus if they have any of the following: A serum bilirubin level greater than 340 micromol/litre in babies with a gestational age of 37 weeks or more A rapidly rising bilirubin level of greater than 8.5 micromol/litre per hour Clinical features of acute bilirubin encephalopathy Infection Prevention 13.1 All staff should follow Trust guidelines on infection control by ensuring that they effectively decontaminate their hands before and after undertaking any patient contact Staff and Training 14.1 All medical, midwifery and nursing staff involved in the care of infants at risk of hyperbilirubinaemia will be trained to identify the symptoms of hyperbilirubinaemia and its treatment. This will be recorded as part of their appraisal All staff will be aware of the correct equipment to use and the correct way to perform heel pricks to obtain capillary blood, and be competent at using the transcutaneous bilirubinometer 14.3 All midwifery and obstetric staff must attend yearly mandatory training which includes skills and drills training All midwifery and obstetric staff are to ensure that their knowledge and skills are up-to date in order to complete their portfolio for appraisal Audit and Monitoring 15.1 Audit of compliance with this guideline will be considered on an annual audit basis in accordance with the Clinical Audit Strategy and Policy, the Maternity annual audit work plan and the NHSLA/CNST requirements. The Audit Lead in liaison with the Risk Management Group will identify a lead for the audit The findings of the audit will be reported to and approved by the Multi-disciplinary Risk Management Group (MRMG) and an action plan with named leads and timescales will be developed to address any identified deficiencies. Performance against the action plan will be monitored by this group at subsequent meetings The audit report will be reported to the monthly Directorate Governance Meeting (DGM) and significant concerns relating to compliance will be entered on the local Risk Assurance Framework Key findings and learning points from the audit will be submitted to the Patient Quality and Safety Committee (PSQC) within the integrated learning report. 8

9 15.5 Key findings and learning points will be disseminated to relevant staff Guideline Management 16.1 As an integral part of the knowledge, skills framework, staff are appraised annually to ensure competency in computer skills and the ability to access the current approved guidelines via the Trust s intranet site Quarterly memos are sent to line managers to disseminate to their staff the most currently approved guidelines available via the intranet and clinical guideline folders, located in each designated clinical area Guideline monitors have been nominated to each clinical area to ensure a system whereby obsolete guidelines are archived and newly approved guidelines are now downloaded from the intranet and filed appropriately in the guideline folders. Spot checks are performed on all clinical guidelines quarterly Quarterly Clinical Practices group meetings are held to discuss guidelines. During this meeting the practice development midwife can highlight any areas for future training needs that will be met using methods such as workshops or to be included in future skills and drills mandatory training sessions Communication 17.1 A quarterly maternity newsletter is issued to all staff with embedded icons to highlight key changes in clinical practice to include a list of newly approved guidelines for staff to acknowledge and familiarise themselves with and practice accordingly. Midwives that are on maternity leave or bank staff have letters sent to their home address to update them on current clinical changes Approved guidelines are published monthly in the Trust s Staff Focus that is sent via to all staff Approved guidelines will be disseminated to appropriate staff quarterly via Regular memos are posted on the guideline and audit notice boards in each clinical area to notify staff of the latest revised guidelines and how to access guidelines via the intranet or clinical guideline folders References National Institute for Health and Clinical Excellence (2010) Neonatal jaundice Clinical Guideline NICE: May. American Academy of Pediatrics (2004) Management of hyperbilirubinaemia in the newborn infant 35 or more week s gestation. Pediatrics vol114 pp Manning D, Todd P, Maxwell M, Platt MJ (2007) Prospective study of severe hyperbilirubinaemia in the newborn in the UK and Ireland. Arch. Dis. Child. Fetal Neonatal ed. Vol92 F Morris BH et al (2008) Aggressive vs. Conservative phototherapy for infants with extremely low birth weight. N England J Med vol 359 pp1885 Watchko JF, Maisels MJ, (2003) Jaundice in low birth weight infants: pathobiology and outcome. Arch. Dis. Child. Fetal neonatal ed. 88 F Watchko JF, Maisels MJ, (2003) Treatment of Jaundice in low birth weight infants. Arch. Dis. Child. Fetal neonatal ed. 88 F

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