Emergency management of extreme hyperbilirubinemia

Extreme hyperbilirubinemia is rare and considered a medical emergency. The American Academy of Pediatrics (AAP) recommends shortening any delay in the diagnosis and treatment of these cases. However, the critical care monitoring and management of these cases have not been described in detail. This may contribute to significant treatment delays (e.g., failure to recognize signs of bilirubin neurotoxicity or provide an efficient vascular access). Here, we offer guidance to provide accurate monitoring to recognize bilirubin neurotoxicity and prompt interventions by using modern techniques such as amplitude-integrated electroencephalography (aEEG) and point-of-care ultrasound to guide vascular access. We also review the literature regarding exchange-transfusions (EXT) in light of recently accumulated evidence and offer a classification of EXT based on the involved vessels, the type of catheter, and techniques, describing their advantages and disadvantages.