hyperbili baby managment question

[migm]

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Folks,

I had a 6d old infant, full term, svd, no trauma, in ED for hyperbili eval, it was nonhemolytic. Bili was ~24 and change when we evaled the pt. No other signs of infection, no resp distress, etc, just isolated hyperbili and ??likely breast feeding jaundice as the kiddo was falling asleep during many feeds but otherwise going 15-20m per breast q3 hr (pretty reasonable).

Anyway, put the kiddo under lights and a billiblanket and he immediately decided to just not breathe as good. I'm talking 85-86% with a good waveform, RR 50s. Lungs clear, no fever/hypot. This was occuring asleep, just chillin under the tanning lights with the glasses on. No other meds on board. Awake sat was 94%. We siwtched out the pulse ox and still - same thing.

I was told that this was something a side effect of bili lights which I find hard to believe. My concern was that this potentially a manifestation of sepsis or, worse, bilirubin encepalopathy. Kid woke up just fine to voice or stimulation. We did a sepsis r/o including CSF and started BSA.. is this crazy? what would you guys have done? PCV was fine by the way. So was the chest xray. I had no great explanation for just sudden onset of hypoxia. Thoughts?

 

[Birdstrike]

I have not heard of that. I know phototherapy can cause watery diarrhea, because my kid had it. But hypoxia? Hmm....

Where was the conversation with the kids pediatrician in all this? If this was common with phototherapy, a pediatrician could answer that in 2 seconds. I've never heard that, though. Seems odd. Who was the one that told you that?

 

[The White Coat Investor]

Folks,

I had a 6d old infant, full term, svd, no trauma, in ED for hyperbili eval, it was nonhemolytic. Bili was ~24 and change when we evaled the pt. No other signs of infection, no resp distress, etc, just isolated hyperbili and ??likely breast feeding jaundice as the kiddo was falling asleep during many feeds but otherwise going 15-20m per breast q3 hr (pretty reasonable).

Anyway, put the kiddo under lights and a billiblanket and he immediately decided to just not breathe as good. I'm talking 85-86% with a good waveform, RR 50s. Lungs clear, no fever/hypot. This was occuring asleep, just chillin under the tanning lights with the glasses on. No other meds on board. Awake sat was 94%. We siwtched out the pulse ox and still - same thing.

I was told that this was something a side effect of bili lights which I find hard to believe. My concern was that this potentially a manifestation of sepsis or, worse, bilirubin encepalopathy. Kid woke up just fine to voice or stimulation. We did a sepsis r/o including CSF and started BSA.. is this crazy? what would you guys have done? PCV was fine by the way. So was the chest xray. I had no great explanation for just sudden onset of hypoxia. Thoughts?

You did bili lights in the ED? I can't say I've ever done that.

I wonder if the lights were affecting the pulse oximeter somehow? Different spectrums but maybe there is some kind of weird thing going on there. Could have tested that by moving him out of the lights and seeing if it instantly ticked up.

 

[RustedFox]

Pulse ox in the 85-90 range and no distress screams hemoglobinopathy to me.

 

[turkeyjerky]

Ambient Light Interference
Intense white or infrared light might interfere with pulse oximetry and lead to falsely low SPO2 readings. This phenomenon, known as the “flooding” effect, is caused by the excessive increase of the light energy that literally floods the photodetector and drives the ratio of absorption ratios toward the unit; this corresponds to an SPO2 of 85%.16 Although new-generation devices can detect light interference,16,21,34,68 health care professionals, particularly those who handle neonates exposed to phototherapy, must be aware of this potential limitation. Ambient light interference can be avoided by simply covering the sensor with nontransparent material.

http://pediatrics.aappublications.org/content/128/4/740.full

So maybe a combination of slight hypoventilation during sleep and the UV light? I know basically every bronchiolitic I have gets a little more hypoxic while sleeping.

 

[Birdstrike]

You did bili lights in the ED? I can't say I've ever done that.

Yeah, I know. Was this in an ED? Did the parents bring the light set up in? (They are portable.) What was the primary complaint? Certainly it was not "My baby is desatting during sleep."

Was it breathing rapidly? Coughing? Lethargic? Or just yellow and the parents were freaked out? This is a very incomplete story, and neonatal jaundice is such bread and butter peds, these rarely end up in the ED unless there's some other symptom or issue. Without a chief complaint, the bili level and the sleeping 02 sat are practically meaningless.

 

[migm]

I have not heard of that. I know phototherapy can cause watery diarrhea, because my kid had it. But hypoxia? Hmm....

Where was the conversation with the kids pediatrician in all this? If this was common with phototherapy, a pediatrician could answer that in 2 seconds. I've never heard that, though. Seems odd. Who was the one that told you that?

I talked ot the pediatrician - he did not seem to think this was a typical response to phototherapy. The nurse was the one who mentioned it. My attending was more worried about sepsis.

You did bili lights in the ED? I can't say I've ever done that.

I wonder if the lights were affecting the pulse oximeter somehow? Different spectrums but maybe there is some kind of weird thing going on there. Could have tested that by moving him out of the lights and seeing if it instantly ticked up.

Wish I had thought of that - just covering it would have been a good idea. Didn't think of the UV light, and the quick google search I found said that bilirubin/jaundice shouldn't affect sp02 given a different wavelength absortion.

Pulse ox in the 85-90 range and no distress screams hemoglobinopathy to me.

Noted - will add this to my thought process..

http://pediatrics.aappublications.org/content/128/4/740.full

So maybe a combination of slight hypoventilation during sleep and the UV light? I know basically every bronchiolitic I have gets a little more hypoxic while sleeping.

No evidence of bronchiolitis - and this is a great post. It is probably what happened. The sepsis w/u was negative (the suspicion was definitely low to begin with).. I am shocked that the NICU didn't bring this up as a common side effect when I talked ot them. In fact they immedialtey said "well thats not normal.." and this is at a quartenary academic center..

Yeah, I know. Was this in an ED? Did the parents bring the light set up in? (They are portable.) What was the primary complaint? Certainly it was not "My baby is desatting during sleep."

Was it breathing rapidly? Coughing? Lethargic? Or just yellow and the parents were freaked out? This is a very incomplete story, and neonatal jaundice is such bread and butter peds, these rarely end up in the ED unless there's some other symptom or issue. Without a chief complaint, the bili level and the sleeping 02 sat are practically meaningless.

Yes this was at a level 1 peds ED - we see a ton of these every week. The story was that parents were at a checkup and bili was elevated so the pediatrician sent the kid in. Mild tachypnea at best, upper 40s- low 50s, no cough, no lethargy. Just yellow. I think one needs to consider sepsis as a possibility in the kiddo but I agree that an isolated vital sign is kindof borderline for initiating the workup but this is what the ED attdg and the NICU fellow thought was reasonable.

 

[Birdstrike]

I talked ot the pediatrician - he did not seem to think this was a typical response to phototherapy. The nurse was the one who mentioned it. My attending was more worried about sepsis.



Wish I had thought of that - just covering it would have been a good idea. Didn't think of the UV light, and the quick google search I found said that bilirubin/jaundice shouldn't affect sp02 given a different wavelength absortion.



Noted - will add this to my thought process..



No evidence of bronchiolitis - and this is a great post. It is probably what happened. The sepsis w/u was negative (the suspicion was definitely low to begin with).. I am shocked that the NICU didn't bring this up as a common side effect when I talked ot them. In fact they immedialtey said "well thats not normal.." and this is at a quartenary academic center..



Yes this was at a level 1 peds ED - we see a ton of these every week. The story was that parents were at a checkup and bili was elevated so the pediatrician sent the kid in. Mild tachypnea at best, upper 40s- low 50s, no cough, no lethargy. Just yellow. I think one needs to consider sepsis as a possibility in the kiddo but I agree that an isolated vital sign is kindof borderline for initiating the workup but this is what the ED attdg and the NICU fellow thought was reasonable.

No direct admit? Do you have phototherapy set ups in your ED? Or did they just want labs repeated right away. I don't know. The ED certainly is convenient. It's hard to judge over an Internet forum (reason for edit) but an interesting discussion nonetheless.

 

[migm]

At 24.6 this was awfully close to saturating to the level necessary for exchange txfusion

 

[Birdstrike]

At 24.6 this was awfully close to saturating to the level necessary for exchange txfusion

Is that what they ended up doing, or just light therapy?

My guess: just the light.