Orimadegun Adebola Emmanuel, Akingbola Titilola Stella
1 Institute of Child Health, College of Medicine, University of Ibadan, Ibadan, Nigeria2 Department of Haematology, College of Medicine, University of Ibadan, Ibadan, Nigeria3 Joanna Briggs Institute Evidence Synthesis Group: Nigeria.
JBI Database System Rev Implement Rep. 2015 Jan;13(1):134-45. doi: 10.11124/jbisrir-2015-1963.
REVIEW QUESTION/OBJECTIVE: The objective of this review is to assess the effectiveness of intravenous calcium given during exchange blood transfusion (EBT) in neonates.More specifically, the objectives of the review are to determine whether:
Neonatal hyperbilirubinaemia is an abnormally high level of bilirubin in the circulating blood, resulting in clinically visible icterus or jaundice. A serum bilirubin level above 5 mg per dL (86 μmol per L) is a frequently encountered problem worldwide and is a common reason for neonates to present to the emergency department.Unconjugated bilirubin is toxic to infants' brains when the concentration exceeds a certain level. An unconjugated serum bilirubin concentration at toxicity level is described as 'severe hyperbilirubinaemia'. The concentrations that define toxic level vary, depending on the gestational age of the neonates and fetal maturity.Severe hyperbilirubinaemia can cause encephalopathy if not promptly treated, with significant complications such as athetoid cerebral palsy, sensorineural hearing loss, paralysis of upward gaze, dental enamel dysplasia and death.Recent reports indicate that these conditions, though rare, are still occurring despite the availability of efficient methods for treatment of hyperbilirubinaemia and its prevention.These complications can be prevented if the level of bilirubin is reduced rapidly with exchange blood transfusion.Exchange blood transfusion (EBT) is the most rapid and effective method for lowering serum bilirubin concentrations, but it is rarely needed when intensive phototherapy is effective.In the presence of hemolytic disease, severe anaemia, or a rapid rise in the total serum bilirubin level (greater than 1 mg per dL per hour in less than six hours), EBT is the recommended treatment. EBT also removes partially hemolyzed and antibody-coated erythrocytes and which is then replaced with uncoated donor red blood cells. If intensive phototherapy fails to lower the bilirubin level, then EBT is always considered as the next line of treatment in any newborn with non-hemolytic jaundice.Complications of EBT can include hypocalcaemia, seizures and even death within 24 hours. The potential seriousness of these complications makes clinicians consider intensive phototherapy before EBT.However, the option of intensive phototherapy may not be feasible and could be quite ineffective in resource limited settings where the required facilities and electrical power supply are inadequate. Under these circumstances neonates with severe hyperbilirubinaemia will most likely be treated with EBT.Exchange transfusion of blood collected with acid-citrate-dextrose (ACD) containing bags may produce hypocalcaemia.To decrease the morbidity from chelation of divalent cations by citrate, routine administration of calcium gluconate during EBT was advocated,but tetany, convulsion and death may still occur when ACD blood is used.However, there are controversies about the effectiveness of intravenous calcium in reducing these calcium-related morbidities. A preliminary search for systematic reviews in MEDLINE, the Cochrane Library, Campbell Library and the Joanna Briggs Database of Systematic Reviews and Implementation Reports failed to identify any existing publications on this topic. As a result, this review will examine current quantitative evidence regarding the effectiveness of routine administration of intravenous calcium during EBT in the treatment of severe hyperbilirubinaemia, with specific aim to describe incidences of hypocalcaemia, seizures and deaths after such a transfusion.
综述问题/目标：本综述的目的是评估新生儿换血疗法（EBT）期间静脉注射钙剂的有效性。更具体地说，本综述的目标是确定是否：
新生儿高胆红素血症是指循环血液中胆红素水平异常升高，导致临床上可见黄疸。血清胆红素水平高于5mg/dL（86μmol/L）是全球常见问题，也是新生儿前往急诊科就诊的常见原因。当未结合胆红素浓度超过一定水平时，其对婴儿大脑有毒性。未结合血清胆红素浓度处于毒性水平时被称为“重度高胆红素血症”。定义毒性水平的浓度因新生儿的胎龄和胎儿成熟度而异。如果不及时治疗，重度高胆红素血症可导致脑病，并伴有手足徐动型脑瘫、感音神经性听力损失、向上凝视麻痹、牙釉质发育不良和死亡等严重并发症。近期报告表明，尽管有治疗和预防高胆红素血症的有效方法，但这些情况虽然罕见，仍有发生。如果通过换血疗法迅速降低胆红素水平，这些并发症是可以预防的。换血疗法（EBT）是降低血清胆红素浓度最迅速有效的方法，但在强化光疗有效的情况下很少需要使用。在存在溶血性疾病、严重贫血或总血清胆红素水平迅速升高（6小时内每小时大于1mg/dL）时，推荐采用EBT治疗。EBT还可清除部分溶血和被抗体包被的红细胞，然后用未包被的供体红细胞替代。如果强化光疗未能降低胆红素水平，那么对于任何非溶血性黄疸新生儿，EBT始终被视为下一步治疗方案。EBT的并发症可能包括低钙血症、惊厥，甚至在24小时内死亡。这些并发症的潜在严重性使临床医生在进行EBT前会考虑强化光疗。然而，在资源有限的环境中，强化光疗可能不可行且效果不佳，因为所需设施和电力供应不足。在这种情况下，重度高胆红素血症的新生儿很可能接受EBT治疗。使用含枸橼酸-葡萄糖（ACD）的采血袋进行换血可能会导致低钙血症。为降低枸橼酸对二价阳离子的螯合所导致的发病率，提倡在EBT期间常规给予葡萄糖酸钙，但使用ACD血时仍可能发生手足搐搦、惊厥和死亡。然而，关于静脉注射钙剂在降低这些与钙相关的发病率方面的有效性存在争议。对MEDLINE、Cochrane图书馆、Campbell图书馆以及Joanna Briggs系统评价与实施报告数据库进行的系统评价初步检索未发现关于该主题的任何现有出版物。因此，本综述将研究关于EBT期间常规静脉注射钙剂治疗重度高胆红素血症有效性的当前定量证据，具体目的是描述这种输血后低钙血症、惊厥和死亡的发生率。
