OSCE viva practiceNeonatal jaundiceAAP 2022
A structured viva on escalation of care in severe hyperbilirubinaemia. Answer each question out loud before you open the model answer, just as you would in front of an examiner.
Whether you can spot when bilirubin has reached the escalation level, act on it as an emergency, and know when an exchange transfusion cannot wait.1
The scenario
A 5-day-old boy, born at 39 weeks and breastfed, is brought to a district hospital that does not provide exchange transfusions. His total serum bilirubin (TSB) is 25.5 mg/dL and his exchange transfusion threshold is 27 mg/dL. His mother is group O, RhD positive. He is alert, with no abnormal neurological signs.
Values are in mg/dL, as the AAP guideline uses (1 mg/dL ≈ 17.1 μmol/L). Suggested time: 8–10 minutes.
01How do you interpret this, and what do you do now?
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- The escalation-of-care threshold is 2 mg/dL below the exchange threshold, which is 25 mg/dL here. His TSB is above it, so this is a medical emergency.1
- Start emergency intensive phototherapy and IV hydration.1
- Contact a neonatologist about urgent transfer to a NICU that can do exchange transfusions. Keep phototherapy and IV fluids going during transfer, and admit him directly to the NICU rather than through the emergency department.1
AAP 2022, Key Action Statements 17 and 19
02Which investigations do you send, and how often do you repeat the TSB?
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- Urgent (STAT) bloods: total and direct bilirubin, full blood count, albumin, serum chemistries, and group and crossmatch.1
- A direct antiglobulin test (DAT), because the mother is group O.1
- G6PD activity if the cause of jaundice is unknown and he needs escalation of care.1
- TSB at least every 2 hours until it falls below the escalation threshold. Do not subtract the direct bilirubin from the total.1
AAP 2022, Key Action Statements 14, 18 and 20
03The DAT is positive and bilirubin keeps rising despite phototherapy. What else could you offer?
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- Intravenous immune globulin (IVIG) 0.5–1 g/kg over 2 hours is an option for isoimmune haemolytic disease once TSB reaches the escalation threshold. It can be repeated after 12 hours.1
- Its limits: it is unclear whether IVIG prevents exchange transfusion, and observational studies link it to necrotising enterocolitis.1,2
- The rest of the escalation-of-care bundle continues alongside it.1
AAP 2022, Key Action Statement 21; AAP technical report
04Thirty minutes later he is arching, with retrocollis and a high-pitched cry. TSB is 26 mg/dL. What now?
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- These are signs of intermediate or advanced acute bilirubin encephalopathy. He needs an urgent exchange transfusion now, even though his TSB is below the exchange threshold.1
- An exchange can be deferred only when TSB has fallen below the threshold and there are no signs of encephalopathy.1
- The preferred blood is washed, crossmatched red cells mixed with fresh frozen plasma to a haematocrit of about 40%.1
AAP 2022, Key Action Statements 22 and 23
05How does albumin change your decisions?
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- An albumin below 3.0 g/dL is a neurotoxicity risk factor, because more bilirubin is left unbound. It moves the baby onto the lower phototherapy and exchange thresholds.1
- The bilirubin-to-albumin ratio (TSB in mg/dL ÷ albumin in g/dL) is used alongside TSB when deciding on exchange. At 38 weeks or more, consider exchange at a ratio of ≥8.0 with no risk factors, or ≥7.2 with at least one risk factor.1
AAP 2022, sections II.B and III.F
Mark yourself
Tick off each point you made without looking. A passing answer covers at least 6 of the 9 points, including all three in red. Missing any red point fails the station, whatever the total.
- Recognised the escalation threshold (exchange threshold minus 2 mg/dL) and treated it as an emergency
- Intensive phototherapy plus IV hydration
- Neonatologist contacted for urgent NICU transfer, with treatment continued in transit
- Full STAT blood panel
- DAT because the mother is group O; G6PD if the cause is unknown
- TSB at least every 2 hours
- IVIG dose, indication and limits
- Urgent exchange transfusion for signs of encephalopathy, even below the threshold
- Albumin below 3.0 g/dL as a risk factor, and the bilirubin-to-albumin ratio cut-offs
The AAP thresholds were designed for high-resource settings and are based on expert opinion rather than trial evidence. Always use the full guideline charts and your local policy.1
References
- Kemper AR, Newman TB, Slaughter JL, et al. Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics. 2022;150(3):e2022058859. doi:10.1542/peds.2022-058859
- Slaughter JL, Kemper AR, Newman TB. Technical Report: Diagnosis and Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics. 2022;150(3). doi:10.1542/peds.2022-058865