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Education  |   April 2018
Intraoperative Phototherapy for Hyperbilirubinemia
Author Notes
  • From the Division of Cardiothoracic Anesthesiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas.
  • Charles D. Collard, M.D., served as Handling Editor for this article.
    Charles D. Collard, M.D., served as Handling Editor for this article.×
  • Address correspondence to Dr. Adler: adamcadler@gmail.com
Article Information
Education / Images in Anesthesiology / Coagulation and Transfusion / Critical Care / Endocrine and Metabolic Systems / Gastrointestinal and Hepatic Systems / Pediatric Anesthesia / Renal and Urinary Systems / Electrolyte Balance
Education   |   April 2018
Intraoperative Phototherapy for Hyperbilirubinemia
Anesthesiology 4 2018, Vol.128, 811. doi:10.1097/ALN.0000000000001925
Anesthesiology 4 2018, Vol.128, 811. doi:10.1097/ALN.0000000000001925
HYPERBILIRUBINEMIA or jaundice when severe and if untreated has disastrous yet preventable neurotoxic effects, specifically, bilirubin-induced encephalopathy or kernicterus.1,2  Intraoperative phototherapy using an underbody bili blanket (red arrows) can minimize treatment interruptions, which is preferential during light therapy. Although dual-source (anterior and posterior) light therapy is preferred, this may not allow for operative access to the patient. As seen in these images, the patient should be positioned to provide maximal light to skin interface, with the cautery pad positioned to allow maximal light exposure. Patients should be well hydrated and have eye shields because phototherapy may result in dehydration from insensible losses and toxicity to the immature retina. Although surgery should be delayed until hyperbilirubinemia is resolved, in emergent or semiurgent cases, maintenance of phototherapy intraoperatively, especially in lengthy cases, should be considered.
Bilirubin is a product of erythrocyte catabolism with a complex degradation and elimination pathway. Phototherapy uses light energy to change the structural configuration of bilirubin converting it to a structural isomer that can be excreted in the urine without the need for conjugation.3 
Bilirubin levels may increase in the hours prior to anesthesia, as reduced caloric intake and dehydration resulting from non per os times reduces bilirubin reabsorption from the gastrointestinal tract.1  Anesthesia providers should communicate with the neonatal intensive care unit to reduce non per os times as well as minimize time away from light therapy treatment, which works best when uninterrupted. The bilirubin level above which the patient would be considered for exchange transfusion should be discussed with the neonatologist according to nomogram guidelines from the American Academy of Pediatrics.1  Preoperative evaluation also should focus on presence of liver dysfunction, which, when combined with hyperbilirubinemia-dependent vitamin K deficiency and/or prematurity, may result in coagulopathy.3  Unless in extreme cases of severe concomitant liver and/or kidney failure, perioperative antibiotics should be administered based on institutional neonatal dosing guidelines. Additionally, neonatal sepsis may result in hyperbilirubinemia and should be considered in the preoperative evaluation.
Competing Interests
The author declares no competing interests.
References
American Academy of Pediatrics Subcommittee on Hyperbilirubinemia: Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004; 114(1):297–316 [Article] [PubMed]
Maisels, MJ, McDonagh, AF . Phototherapy for neonatal jaundice. N Engl J Med 2008; 358:920–8 [Article] [PubMed]
Gregory, GA, Brett, C . Davis, PJ, Cladis, FP, Motoyama, EK . Neonatology for Anesthesiologists, Anesthesia for Infants and Children, 2011, pp 8th edition. Edited by Philadelphia, Elsevier, 512–53 [Article]