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You are the doctor on call in the well baby nursery at the community hospital. One of the nurses calls you to ask about one of your patients. The baby is now 30 hours old and was born full term via vaginal delivery to a healthy 28-year-old mother. There were no complications at the delivery and the baby has been feeding well. The nurse is concerned that the baby looks "yellow". You ask her to send for a bilirubin level. A few hours later she calls to tell you that the total bilirubin level has come back at 18 mg/dL with a direct bilirubin level of 0.6 mg/dL. The parents are now concerned about the baby's discoloration. The most appropriate next step is to
A. reassure the mother that this is completely normal and no additional studies or treatment are indicated
B. repeat the bilirubin level immediately as the result must be a lab error
C. start phototherapy and repeat the bilirubin level in 6 hours
D. transfer to the nearest neonatal intensive care unit for an exchange transfusion
E. wait 6 hours and repeat the bilirubin level
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ee....i believe its physio jaundice..bt bili is way to high...so lets recheck in 6 hrs....
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The correct answer is C. Jaundice is a common occurrence in the first week of life. "Physiologic jaundice" is usually transient and is due to an increased bilirubin load from increased red blood cell volume, decreased survival time of the red blood cell, and an increased enterohepatic circulation. Other factors include defective hepatic uptake of bilirubin and inadequate conjugation of bilirubin to bilirubin glucuronide for excretion. A normal cord blood bilirubin level is about 1.5 mg/dl, and a neonate's serum bilirubin normally increases by a maximum of 5mg/dl in 24 hours to a maximum of about 15mg/dl at 3 days of life. A level of 18mg/dl at 30 hours of life is not normal and requires phototherapy to bring the level down. Phototherapy should bring the level down by 1-2mg/dl within 4-6 hours. The level should be checked at that time to ensure that the level has not continued to rise. Besides phototherapy, an investigation into the cause for the rapid rise of bilirubin should be undertaken. The most important consideration is the blood type of the mother and the blood type of the infant. A direct Coombs test should also be performed. Other things to keep in mind include a red cell defect such as an hemoglobinopathy, polycythemia, extravascular blood loss, bacterial sepsis, increased enterohepatic circulation (from an intestinal obstruction), disorder of bilirubin metabolism, or an endocrine disorder such as hypothyroidism.
Reassurance that this is completely normal (choice A) is incorrect. This baby needs to be treated for hyperbilirubinemia and more blood will need to be drawn to follow the levels. The mother should be reassured that this is a common occurrence, that is usually transient, and has no future implications on the baby's development, if treated appropriately.
Repeating the labs (choice B) is not correct because although lab error is something to keep in mind when interpreting all test results, this baby is jaundiced and therefore it is unlikely to have a normal bilirubin level. Jaundice usually becomes apparent at levels of 5mg/dl in the neonate. As levels get higher, the jaundice usually progresses from the face to the trunk and then down the body.
An exchange transfusion (choice D) is not yet warranted in this baby. If the level were greater than 25mg/dl or started at greater than 20 mg/dl and did not improve with phototherapy, this baby would require an exchange transfusion. During this procedure, blood is removed from the baby (usually from an umbilical artery catheter), and the baby is transfused with cross matched blood through a venous catheter. The exchange is done in 15ml increments. There are multiple risks to the procedure including thromboemboli, dysrhythmias, hyperkalemia, hypernatremia, DIC, and transfusion reaction. And thus answer D is not correct.
Wait 6 hours and repeat the level (choice E) is incorrect because the bilirubin level is too high to allow you to wait and watch. If the bilirubin level is allowed to rise unchecked the baby is put at risk for kernicterus. When the level of unconjugated bilirubin reaches higher than 20mg/dl in a full-term neonate, it can become neurotoxic by accumulating in the basal ganglia, pons, or cerebellum causing kernicterus. Clinically, it manifests as a variety of neurologic symptoms ranging from lethargy and hypotonia to severe encephalopathy and death. At the present rate of rise, the bilirubin is likely to be higher than 20 mg/dlin 6 hours.
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good 1 for ck even..i m preparing for ck...
