364 Section IX ■ Miscellaneous Procedures

3. Clean proximal tibia with antiseptic solution.

4. Put on sterile gloves.

5. Apply aperture drape.

6. If appropriate, inject lidocaine into skin, soft tissue, and

periosteum (13).

Table 50.1

Types of Intraosseous Infusates

Reported in the Literature

(4,5,17,19,23)

1. Fluids

a. Normal saline

b. Crystalloids

c. Glucose (dilute if possible when using D50) (17,24)

d. Ringer’s lactate (19)

2. Blood and blood products

3. Medications

a. Anesthetic agents

b. Antibiotics

c. Atropine (19)

d. Calcium gluconate

e. Dexamethasone (19)

f. Diazepam(19)

g. Diazoxide (19); phenytoin (25)

h. Dobutamine (23)

i. Dopamine (23,24,26)

j. Ephedrine (27)

k. Epinephrine (27)

l. Heparin (19)

m. Insulin

n. Isoproterenol (26)

o. Lidocaine

p. Morphine

q. Sodium bicarbonate (dilute if possible) (17,28)

4. Contrast material (29)

BONE MARROW NEEDLE

1 CC LIDOCAINE

5 CC SYRINGE

5 CC NORMAL SYRINGE

IV TUBING

STERILE DRAPES CHLORHEXIDINE SWABS

STERILE GLOVES

STERILE GAUZE PADS

3 WAY STOPCOCK

SPINAL NEEDLE

HYPODERMIC NEEDLE

Fig. 50.1. Sterile equipment necessary for intraosseous line placement.

7. Determine penetration depth on needle: Rarely more than

1 cm in infants or 0.5 cm in small premature infants.

a. For needle or bone needle injection device with

adjustable depth indicator, adjust sheath to allow

desired penetration.

b. For needle without an adjustable depth indicator,

hold the needle in the dominant hand with blunt

end supported by the palm and the index finger

approximately 1 cm from the bevel of the needle to

avoid pushing it past this mark.

8. Palpate tibial tuberosity with index finger (Fig. 50.3).

 

362 Section IX ■ Miscellaneous Procedures

23. Kaplan M, Kaplan E, Hammerman C, et al. Post phototherapy

neonatal rebound: a potential cause of significant hyperbilirubinemia. Arch Dis Child. 2006;91:31.

24. Rubaltelli F, Da Riol R, D’Amore ES, et al. The bronze baby syndrome: evidence of increased tissue concentration of copper porphyrins. Acta Pediatr. 1996;85:381.

25. Paller AS, Eramo LR, Farrell EE, et al. Purpuric phototherapy

induced eruption in transfused neonates: relation to transient porphyrinemia. Pediatrics. 1997;100:360.

26. DeCurtis M, Guandalini S, Fasano A, et al. Diarrhea in jaundiced neonates treated with phototherapy: role of intestinal secretion. Arch Dis Child. 1989:64:1161.

27. Mahe E, Beauchet A, Aegerter P, et al. Neonatal blue light phototherapy does not increase nevus count in 9 year old children.

Pediatrics. 2009;123:e896.

28. Hunter JJ, Morgan JL, Merigan WH, et al. The susceptibility of

the retina to photochemical damage from visible light. Prog Retin

Eye Res. 2012;31:28.

 

J Perinatol. 2003;23:123.

15. Roll EB, Christensen T. Formation of photoproducts and cytotoxicity of bilirubin irradiated with turquoise and blue phototherapy

light. Acta Pediatr. 2005;94:1448.

16. Tan KL. Comparison of the efficacy of fiberoptic and conventional phototherapy for neonatal hyperbilirubinemia. J Pediatr.

1994;125:607.

17. Vreman HJ, Wong RJ, Stevenson DK, et al. Light emitting diodes:

a novel light source for phototherapy. Pediatr Res. 1998;44:804.

18. Seidman DS, Moise J, Ergaz Z, et al. A new blue light emitting

phototherapy device: a prospective randomized controlled study.

J Pediatr. 2000;136:771.

19. Kumar p, Murki S, Chawla D, et al. Light emitting diodes vs compact fluorescent tubes for phototherapy in neonatal jaundice: a

multicenter randomized controlled trial. Indian Pediatr.

2010;47:131.

20. Eggert P, Stick C, Schroder H. On the distribution of irradiation

intensity in phototherapy. Measurements of effective irradiance in

an incubator. Eur J Pediatr. 1984;142:58.

21. Kardson J, Schothorst A, Ruys JH, et al. Plastic blankets and heat

shields decrease transmission of phototherapy light. Acta Paediatr

Scand. 1986;75:555.

22. Maisels MJ, Kring E. Bilirubin rebound following intensive phototherapy. Arch Pediatr Adolesc Med. 2002;156:669.

 

360 Section IX ■ Miscellaneous Procedures

without causing overheating, but halogen spot phototherapy lamps should not be positioned closer to the

infant than recommended by the manufacturer,

because of the risk of burns (10).

2. If increased irradiance is required, add additional units

or place a fiberoptic phototherapy pad under the infant

(10,16). Additional surface area may be exposed to phototherapy by lining the sides of the bassinet with aluminum foil or a white cloth (20).

3. Keep the photoradiometer calibrated and perform periodic checks of phototherapy units to make sure that

adequate irradiance is being delivered (10).

4. Maintain an intact acrylic/safety glass shield over phototherapy light bulbs to block ultraviolet radiation and

to protect the infant from accidental bulb breakage.

5. Provide ventilation to the phototherapy unit to prevent

overheating light bulbs.

6. Maintain cleanliness and electrical safety.

E. Technique (Fiberoptic Phototherapy)

Fiberoptic phototherapy can be used as the sole source of

phototherapy or as an adjunct to conventional treatment.

1. Insert the panel into disposable cover so that it is flat

and directed toward the infant.

2. Place the covered panel around the infant’s back or

chest and secure in position. The phototherapy blanket/pad must be positioned directly next to the infant’s

skin to be effective. Avoid constriction and skin irritation under the infant’s arms if the panel is wrapped

around the infant.

3. Discard disposable covers after each treatment and

when soiled.

4. Use eye patches if there is any direct exposure to lights

in panel or if used with conventional phototherapy for

double-sided effect.

5. Ensure stability and adequate ventilation of the illuminator unit by placing it on a secure surface.

6. Connect the fiberoptic panel to illuminator.

7. Keep the fiberoptic panel and illuminator clean and dry.

8. Allow the lamp to cool for 10 to 20 minutes before moving the illuminator. Do not place sharp or heavy objects

on the panel or cable.

Care of the Infant Receiving Phototherapy

1. Monitor temperature, particularly of infants in an incubator, who may develop hyperthermia.

2. Monitor intake, output, and weight. Fluid supplementation may be necessary secondary to increased insensible losses and frequent stooling. Encourage breastfeeding. Healthy term breast-fed infants may be

supplemented with milk-based formula if maternal

milk supply is inadequate. IV fluids are rarely required.

Milk feeding inhibits the enterohepatic circulation of

bilirubin (1).

3. The use of eye protection in the form of eye patches is

necessary for infants receiving overhead phototherapy.

Masks adhering directly to Velcro tabs on the temples

are preferable to circumferential headbands.

4. Maximize skin exposure to phototherapy source by

using the smallest possible diapers as well as keeping

blanket rolls from blocking light.

5. Avoid fully occlusive dressings, bandages, topical skin

ointments, and plastic in direct contact with the infant’s

skin, to prevent burns.

6. Remove plastic heat shields and plastic wrap that

decrease irradiance delivered to the skin (21).

7. If in use, shield the oxygen saturation monitor probe

from the phototherapy light.

8. Encourage parents to continue feeding, caring for, and

visiting their infant.

F. Home Phototherapy

Home phototherapy decreases costs of hospitalization and

eliminates separation of mother and infant. It is safe and

effective for selected infants. Home phototherapy should be

used only in infants whose bilirubin levels are in the

“optional phototherapy” range (Fig. 49.1).

1. Make arrangements to measure the infant’s serum bilirubin every 12 to 24 hours, depending on the previous

concentration and rate of rise. The infant should be

examined daily by a visiting nurse or at an office.

2. The supervising physician should be in contact with

the family daily during the period of treatment.

3. The infant should be rehospitalized if he or she shows

signs of illness or if the serum bilirubin concentration

exceeds 18 mg/dL.

G. Efficacy of Phototherapy

The clinical impact of effective phototherapy should be evident within 4 to 6 hours of initiation, with a decrease of

more than 2 mg/dL (34 mmol/L) in serum bilirubin concentration. The clinical response depends on the rates of

bilirubin production, tissue deposition and elimination,

and photochemical reactions of bilirubin. The therapeutic

efficacy of phototherapy depends on several factors.

1. Exposed body surface area: The greater the area exposed,

the greater the rate of bilirubin decline.

2. Distance of the infant from the light source

3. Skin thickness and pigmentation

4. Total bilirubin at clinical presentation

5. Duration of exposure to phototherapy

 

Chapter 49 ■ Phototherapy 361

H. Discontinuation of Phototherapy

and Follow-Up

1. There is no single standard for discontinuing phototherapy. The total serum bilirubin (TSB) level that

determines the discontinuation of phototherapy

depends on the age of the infant, the age and bilirubin

level at which treatment was initiated, and the etiology

of the hyperbilirubinemia (1,22).

2. For infants who are readmitted to the hospital (usually

for TSB levels of 18 mg/dL or higher), phototherapy

may be discontinued when the serum bilirubin level

falls below 13 to 14 mg/dL.

3. For infants who are readmitted with hyperbilirubinemia and then discharged, significant rebound is

uncommon, but may still occur. In cases of prematurity, positive direct antiglobulin (Coombs) test, and for

babies treated <72 hours, the likelihood of rebound is

much higher, and these risk factors should be

taken into account when planning postphototherapy

follow-up (23). Generally, a follow-up bilirubin measurement within 24 hours after discharge is recommended (1).

I. Complications of Phototherapy

“Phototherapy has been used in millions of infants for more

than 30 years, and reports of significant toxicity are exceptionally rare” (1).

Complications include the following.

1. “Bronze baby syndrome” occurs in some infants with

cholestatic jaundice who are exposed to phototherapy,

as a result of accumulation in the skin and serum of

porphyrins. The bronzing disappears in most infants

within 2 months (24). Rare complications of purpuric

eruptions due to transient porphyrinemia have been

described in infants with severe cholestasis who receive

phototherapy (25).

2. Diarrhea or loose stools (26)

3. Dehydration secondary to insensible water loss

4. Skin changes ranging from minor erythema, increased

pigmentation, and skin burns, to rare and more severe

blistering and photosensitivity in infants with porphyria

and hemolytic disease. Concerns about an increase in

the number of melanocytic nevi have not been substantiated (27).

5. Although there is a risk of potential retinal damage

from light exposure, adverse effects have not been

reported in neonates because eye patches are used routinely (28).

6. Separation of mother and infant and interference with

bonding.

References

1. American Academy of Pediatrics Subcommittee on

Hyperbilirubinemia. Management of hyperbilirubinemia in the

newborn infant 35 or more weeks of gestation. Pediatrics. 2004;

114:297.

 

Treatable Body

Surface Area (%)

Spectrum,

Total (nm)

Bandwidtha

(nm)

Peak

(nm)

Footprint

Irradiance

(mW/cm2

/nm)

Mean ± SD

Light Emitting

Diodes

NeoBLUE

Natus Medical, San Carlos, CA 30 100 420–450 20 462 30 ± 7

Fluorescent

BiliLite CW/BB

BiliLite BB

BiliLite TL52

BiliBed

Olympic Medical, San Carlos, CA

Olympic Medical, San Carlos, CA

Olympic Medical, San Carlos, CA

Medela,

McHenry, IL

45

45

45

0

100

100

100

71

380–720

400–550

400–626

400–560

69

35

69

80

578

445

437

450

8 ± 1

17 ± 2

19 ± 3

36 ± 2

Halogen

MiniBiliLite

Phototherapy Lite

Olympic Medical, San Carlos, CA

Philips Inc, Andover, MA

45

45

54

54

350–800

370–850

190

200

580

590

7 ± 5

5 ± 5

Halogen

fiberoptic

Biliblanket

Wallaby II Preterm

WallabyII Term

SpotLight 1000

PEP Model 2000

BiliSoft

Ohmeda,

Fairfield, CT

Philips, Inc, Andover, MA

Philips, Inc, Andover, MA

Philips, Inc, Andover, MA

PEP

Fryeburg, ME

GE Healthcare, Laurel, MD

0

0

0

45

23

0

24

19

53

54

100

71

390–600

400–560

400–560

400–560

400–717

400–670

70

45

45

45

63

40

533

513

513

513

445

453

20 ± 6

16 ± 6

8 ± 1

6 ± 3

28 ± 11

25 ± 16

a

Spectral bandwidth defined as the width of the emission spectrum in nm at 50% of peak light intensity.

From Bhutani VK, the Committee on Fetus and Newborn. Phototherapy to prevent severe neonatal hyperbilirubinemia in the newborn infant 35 or more weeks of gestation.

Pediatrics. 2011;128:e1046.

 

a

Rhesus disease, perinatal asphyxia, hypoxia, acidosis, hypercapnia.

From Maisels MJ, Watchko JF. Treatment of jaundice in low birthweight infants.

Arch Dis Child Fetal Neonatal Ed. 2003;88:F459.

Chapter 49 ■ Phototherapy 359

b. The pad emits insignificant levels of heat, so it can

be placed in direct contact with the infant to deliver

up to 35 mW/cm2

/nm of spectral irradiance, mainly

in the blue–green range (16).

c. The orientation of the fiberoptic fibers determines

the uniformity of emission and is unique to each of

the commercially available devices.

d. The main advantages of these systems are that,

while receiving phototherapy, the infant can be held

and/or nursed, thereby minimizing infant–parent

separation. In addition, covering the infant’s eyes is

not necessary, preventing further parental anxiety.

e. The main disadvantage of the fiberoptic pads is that

they cover a relatively small surface area and, therefore, have less efficacy compared to overhead

sources. They should not be used as the sole means

of providing phototherapy in an infant with significant hyperbilirubinemia (1,2,11).

f. These devices are often used as an adjunct to conventional overhead application of phototherapy to

provide “double” phototherapy (circumferential

phototherapy), which has greater efficacy because

greater body surface area is exposed to the light

(10,16).

7. Gallium nitride light-emitting diodes (LEDs)

a. These systems are semiconductor phototherapy

devices capable of delivering high spectral irradiance levels of >200 μW/cm2

/nm with very little generation of heat within a very narrow emission spectrum in the blue range (460 to 485 nm), with low

infrared emission and no ultraviolet emission

(10,17,18).

b. LEDs have a longer lifetime (>20,000 hours) and

have become cost-effective for use in phototherapy

devices. LEDs and compact fluorescent tubes are

equally efficacious in the management of hyperbilirubinemia (19).

D. Technique (Conventional

Phototherapy)

Intensive phototherapy is defined as the use of light in the

430- to 490-nm band delivered at 30 mW/cm2

/nm or higher

to the greatest body surface area possible (1,10).

1. Position the phototherapy unit over the infant to obtain

desired irradiance (10 to 40 μW/cm2

/nm). The maximal amount of irradiance achieved by the standard

technique is generally 30 to 50 μW/cm2

/nm. The distance of the light from the infant has a significant effect

on the intensity of phototherapy, and to achieve maximal intensity, the lights should be positioned as close as

possible to the infant. Fluorescent tubes may be

brought within approximately 10 cm of term infants

Table 49.2 Phototherapy Devices Commonly Used in the United States, and Their

Performance Characteristics

Device Manufacturer

Distance to

Patient (cm)

 

Sepideh Nassabeh-Montazami

49 Phototherapy

Phototherapy is the most common therapeutic intervention

used for the treatment of hyperbilirubinemia (1).

Phototherapy causes three reactions: configurational and

structural isomerization of the bilirubin molecule and

photo-oxidation, leading to polar, water-soluble photoproducts that can be excreted in bile and urine without the need

for conjugation or further metabolism (2).

The aim of phototherapy is to reduce serum bilirubin

levels to decrease the risk of acute bilirubin encephalopathy

and the more chronic sequel of bilirubin toxicity, kernicterus (1). High-intensity phototherapy significantly reduces

the total serum bilirubin (TSB) and decreases the need for

exchange transfusion (3).

A. Indications

1. Clinically significant indirect hyperbilirubinemia.

Indications to start phototherapy in babies with hyperbilirubinemia vary depending on gestational age, birthweight, hours of life, presence of hemolysis, and other

risk factors such as acidosis and sepsis (1,4).

2. The TSB level must be considered when making the

decision to commence treatment, as there is significant

variability in laboratory measurement of direct bilirubin levels (5).

3. The American Academy of Pediatrics has published

clinical practice guidelines for phototherapy in

newborn infants at 35 weeks’ or more gestation (1)

(Fig. 49.1).

4. These guidelines do not apply to preterm infants <35

weeks’ gestation. Preterm infants are at higher risk of

developing hyperbilirubinemia compared to term

infants. Although guidelines have been proposed, the

decision to initiate phototherapy in this group of infants

remains variable and highly individualized (4,6)

(Table 49.1).

B. Contraindications

1. Congenital porphyria or a family history of porphyria is

an absolute contraindication to the use of phototherapy. Severe purpuric bullous eruptions have been

described in neonates with congenital erythropoietic

porphyria treated with phototherapy (7).

2. Concomitant use of drugs or agents that are photosensitizers is also an absolute contraindication (8).

3. Concurrent therapy with metalloporphyrin heme oxygenase inhibitors has been reported to result in mild

transient erythema (9).

 

4. Although infants with cholestatic jaundice may develop

the “bronze baby syndrome” when exposed to phototherapy (see H), the presence of direct hyperbilirubinemia is not considered to be a contraindication (1).

However, because the products of phototherapy are

excreted in the bile, the presence of cholestasis may

decrease the effectiveness of phototherapy.

C. Equipment

In order to have an understanding of the equipment available for phototherapy, it is necessary to be familiar with the

terminology involved (10).

1. Spectral qualities of the delivered light (wavelength

range and peak). Bilirubin absorbs visible light within

the wavelength range of 400 to 500 nm, with peak

absorption at 460 ± 10 nm considered to be the most

effective (2).

2. Irradiance (intensity of light), expressed as watts per

square centimeter (W/cm2

), refers to the number of

photons received per square centimeter of exposed

body surface area.

3. Spectral irradiance is irradiance that is quantitated

within the effective wavelength range for efficacy and is

expressed as mW/cm2

/nm. This is measured by various

commercially available radiometers. Specific radiometers are generally recommended for each phototherapy

system, because measurements of irradiance may vary

depending on the radiometer and the light source

(1,10).

A variety of phototherapy equipment devices exist

and may be free-standing, attached to a radiant warmer,

wall-mounted, suspended from the ceiling, or fiberoptic

systems. These in turn may contain various light sources

358 Section IX ■ Miscellaneous Procedures

to deliver the phototherapy. The clinician is, therefore,

 

14. Fridkin SK, Hageman JC, Morrison M, et al. Methicillin-resistant

Staphylococcus aureus disease in three communities. N Engl

J Med. 2005;352:1436.

15. Rudoy RC, Nakashima G. Diagnostic value of needle aspiration

in Haemophilus influenzae type b cellulitis. J Pediatr.1979;94:

924.

16. Garcea G, Lloyd T, Jacobs M, et al. Role of microbiological investigations in the management of non-perineal cutaneous abscesses.

Postgrad Med J. 2003;79:519.

17. Jarratt M, Ramsdell W. Infantile acropustulosis. Arch Dermatol.

1979;115:834.

18. Kahn G, Rywlin AM. Acropustulosis of infancy. Arch Dermatol.

1979;115:831.

19. Loyer EM, DuBrow RA, David CL, et al. Imaging of superficial

soft-tissue infections: sonographic findings in cases of cellulitis

and abscess. Am J Roentgenol. 1996;166:149.

20. Cardinal E, Bureau NJ, Aubin B, et al. Role of ultrasound in musculoskeletal infections. Radiol Clin North Am. 2001; 39:191.

21. Blick PW, Flowers MW, Marsden AK, et al. Antibiotics in surgical

treatment of acute abscesses. Br Med J. 1980;281:111.

22. Fine BC, Sheckman PR, Bartlett JC. Incision and drainage of

soft-tissue abscesses and bacteremia. Ann Intern Med. 1985;

103:645.

23. Feder HM Jr, MacLean WC, Moxon R. Scalp abscess secondary

to fetal scalp electrode. J Pediatr. 1976;89:808.

24. Rudoy RC, Nelson JD. Breast abscess during the neonatal period.

A review. Am J Dis Child. 1975;129:1031.

357

 

7. If indicated, insert plain, 0.5-inch gauze into abscess

cavity to stop bleeding and/or to serve as a wick to promote drainage (Fig. 48.2B).

8. Apply dry, sterile dressing.

9. Remove half of gauze packing in 24 hours and remainder within 48 hours. (Some larger wounds may require

multiple packing changes.)

10. Check abscess wound, and apply sterile warm soaks for

20 to 30 minutes, three times a day, until healing has

commenced, as indicated by

a. Cessation of drainage

b. Formation of granulation tissue

c. Resolution of local tissue inflammation

A B

Fig. 48.2. Drainage of a superficial abscess. A: Breaking the

septa with a clamp. B: Packing the wound.

Fig. 48.1. Superficial abscess in the site of a Broviac central

venous line insertion in the left anterior chest wall.

356 Section IX ■ Miscellaneous Procedures

G. Complications

1. Introduction of infection into sterile abscess or hematoma

2. Local bleeding

3. Injury to blood vessels, nerves, or tendons (deep to

abscess cavity) (5)

4. Incomplete drainage with recurrent abscess formation

(1,3)

5. Systemic infection (21,22)

6. Scar formation at drainage site, requiring skin graft (23)

7. Reduction of breast size following incomplete drainage

of breast abscess (24)

References

1. Meislin HW, Lerner SA, Graves MH, et al. Cutaneous abscesses.

Anaerobic and aerobic bacteriology and outpatient management.

Ann Intern Med. 1977;87:145.

2. Meislin HW, McGehee MD, Rosen P. Management and microbiology of cutaneous abscesses. JACEP. 1978;7:186.

3. Macfie J, Harvey J. The treatment of acute superficial abscesses: a

prospective clinical trial. Br J Surg.1977;64:264.

4. Butler KH. Incision and drainage. In: Roberts JR, Hedges JR, eds.

Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia:

WB Saunders; 2004:717.

5. Albom MJ. Surgical gems. Surgical management of a superficial

cutaneous abscess. J Dermatol Surg. 1976;2:120.

6. Brook I. Microbiology and management of human and animal

bite wound infections. Prim Care.2003;30:25.

7. Folz BJ, Lippert BM, Kuelkens C, et al. Hazards of piercing and

facial body art: a report of three patients and literature review. Ann

Plast Surg. 2000;45:374.

8. Duong M, Markwell S, Peter J, et al. Randomized, controlled trial

of antibiotics in the management of community-acquired skin

abscesses in the pediatric patient. Ann Emerg Med. 2010;55:401.

9. Lee MC, Rios AM, Aten MF, et al. Management and outcome of

children with skin and soft tissue abscesses caused by communityacquired methicillin-resistant Staphylococcus aureus. Pediatr Infect

Dis J. 2004;23:123.

10. Llera JL, Levy RC. Treatment of cutaneous abscess: a doubleblind clinical study. Ann Emerg Med. 1985;14:15.

11. Rajendran PM, Young D, Maurer T, et al. Randomized, doubleblind, placebo-controlled trial of cephalexin for treatment of

uncomplicated skin abscesses in a population at risk for

community-acquired methicillin-resistant Staphylococcus aureus

infection. Antimicrob Agents Chemother. 2007;51:4044.

12. Zetola N, Francis JS, Nuermberger EL, et al. Communityacquired methicillin-resistant Staphylococcus aureus: an emerging threat. Lancet Infect Dis. 2005;5:275.

13. Halvorson GD, Halvorson JE, Iserson KV. Abscess incision and

drainage in the emergency department–Part I. J Emerg Med.

1985;3:227.