Just reading the NICE guidelines on exchange transfusion. This has Bilirubin thresholds for PT and Exchange.

https://www.nice.org.uk/guidance/cg98

What it does not currently address is when the Jaundice after birth is predominantly conjugated. AAP guidance in yester years proposed taking off the direct Bilirubin when it exceeded 50% of the total but I have clinically seen cases in India develop Kernicterus even with a predominantly conjugated jaundice in Sepsis. We had a low threshold for exchange transfusion where we thought benefits exceed risks. I am just curious what the practice is in other units with regards to management of a baby with a conjugated hyperbilirubinemia (Conjugated Jaundice exceeding 50% of the total) where the exchange threshold is exceeded. I am aware aetiology and age as well as gestation and stability would govern management but I am talking about babies in the first 96 hours after birth who clearly are being investigated without ABO or RH incompatibility.

We don’t deduct conjugated bilirubin from total, exchange is done based on total bilirubin. Exchange is not performed in pure conjugated hyperbilirubinemia , as it does not cross BBB. 

Edited October 4, 20214 yr by rehman_naveed

I generally follow NICE guidelines for exchange and don’t do split bilirubin, during first 96hrs.