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  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

  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

  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;14

  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

  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 with

  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 4

  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 n

  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 a

  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 e

  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 ac

  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.