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Chylothorax Case Study
1. CASE STUDY: Post-operative Chylothorax in Infant Jamie Rasmussen Dietetic Intern, 2009-2010 University of Maryland Medical Center
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3. DISEASE OVERVIEW 1 Tetralogy of Fallot (TOF): congenital heart abnormalities that lead to inadequate oxygenation of the blood resulting in cyanosis and shortness of breath. The four defining factors are shown below.
24. Weight Pattern Pt wt not routinely measured as inpatient post-operatively. Expected growth velocity at this age: 25-35 grams/day If pt had grown at expected rate, wt should have been in the range of 3.6-3.8kg by 6/13. 3 rd percentile 4/15 Birth:2.32 kg 4/27: 2.44kg 5/18 3.06 kg 5/21 3.06 kg 6/6: 3.055 kg 6/7: 3.1 kg 6/9: 3.06 kg 6/10: 2.94 kg 6/11: 3.05 kg 6/12: 3.07 kg 6/13: 3.02 kg
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27. TPN PROVISION WITHOUT FLUID LIMIT-6/10 PT ON 1.2X MAINTENANCE FLUID LIMIT Overall provision: 118 kcal/kg (100% estimated needs) Components Notes: D: 20% GIR: 14.2 AA: 3.4% Provides: 3.5g/kg/day Lytes: K+ 2.5 mEq/kg/day (TPN only) 2.5mEq/kg/day total Na 5 mEq/kg/day (TPN only) 5mEq/kg/day total
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34. Fig. 2 Therapeutic algorithm for management of post-operative chylothorax.
Pigtail removed with thought that chyle would likely slow or stop without EN running, still not resolved evening with Enfaport. Pt to have surgery for correction.
Injury to the thoracic duct whether from trauma or surgically, can lead to a leak of chyle from the duct into the surrounding cavities. Patients can develop chylothoraces in the right or left chest cavity depending on the level at which the thoracic duct received injury (above the 6 th thoracic vetebrae usually is a right chylothorax, below is a left). Thoracic duct is largest vessel in the lymph system.
Dopamine-vasocontrictor, pressor Nitroprusside-vasodilator Lasix-diuresis, KCl for repletion from lasix depletion Fentanyl-pain and sedation Estimated needs based on RDA of 108 kcal/kg and 2.2 g/kg protein, kcals decreased while vented 2/2 decreased energy expenditure. Wt used on this note based on initial wt provided in powerchart, new wt entered later in the day and changed to 3.06kg, this wt was used from then on for pt estimates and team medication provisions. Unsure what happened with the difference in wt. Possible that pt actually weighed higher wt, but team entered wt from recent Mt. Washington note to supercede the scale wt from UMMS on admission. Labs-don’t assess prealbumin in these pts, never ordered usually waste of money to see stress status and not nutrition status, no admitting alb for assessment
Also left transition to PO feed recs, monitoring wt and K+ Team not interested in feeding at this time.
Also left transition to PO feed recs with needs estimated to 108 for RDA, monitoring wt and K+ 20kcal/oz=.67kcal/ml 24kcal/oz=.8kcal/ml
Lasix-diuresis, KCl for repletion from lasix depletion Dopamine-vasocontrictor, pressor Pt had also been on erythromycin with enteral feeds.
Same recommendations as initial note for advancement. Also recommended wt checks in every note.
Fluid needs calculated using 100ml/1 st 10 kg, etc. so for a 3.06 kg baby it’s 306ml/day. Major change in note: NPO status Albumin-used for repleting low albumin for losses 2/2 chyle leak and edema Lasix-diuresis, KCl for repletion from lasix depletion Dopamine-vasoconstrictor, pressor Milrinone-vasodilator Epinephrine-vasoconstrictor
Referring back to table on slide 6: prevalence of lymphocytes very characteristic of chyle, high TG content (greater than plasma level norms) and fluid cholesterol lower than plasma level norms, milky appearance
Now recommendation for enteral switched to chyle-leak specific formula, Enfaport.
AA in pediatric pts-trophamine Allowing 233 ml/day Infection complications may be higher with peds pts 2/2 central line options, often place single lumens due to size of lines vs. size of vein. This pt has a TL IJ as of 6/4
Long-chain 3-hydroxyacyl-coenzyme A dehydrogenase ( LCHAD ) deficiency The relevance of this is that MCTs are able to be absorbed directly into the portal system coupled with albumin, whereas LCTs enter the lymph system as chylomicrons 6 which would further stimulate the production and leakage of chyle. We recommended 20 kcal/oz to promote tolerance with a lower osmolality. Were also recommending Sim 20 then changing to Sim 24 once at goal volume.
Full graphic for current TPN order shown on slide 17. Albumin-used for repleting low albumin for losses 2/2 chyle leak and edema Lasix-diuresis, KCl for repletion from lasix depletion Dopamine-vasocontrictor, pressor Milrinone-vasodilator
Enfaport PO 92 ml total, 17 gavaged
Other TPN: 4 Na mEq/kg, 36 mEq/L, K 1mEq/kg 9 mEq/L GIR 16 Estimated needs based on 108 kcal/kg of IBW, pt lacked in wt gain throughout stay NO HYPOKALEMIA!!! Wt: same as admission, my initial showed 3.18kg, two wts taken that day, I had only the first value
Regained birth wt within 2 weeks Lack of wt gain likely 2/2 inadequate nutrition provision
TPN within goal range at this point so adjustments to just maintain lyte values and other labs. Dr. Cardarelli of the cardiology department has not seen a benefit to the use of octreotide in his patients (they all still required surgical ligation for correction if they hadn’t responded to more conservative therapy) so the decision was made to proceed to surgical intervention. Octreotide-safety and efficacy not proved in pediatrics, somatostatin is produced in the body-octreotide is synthetic form, anti-diarrheal, decreases gastric secretions/pancreatic secretions, somehow affects chyle production, not sure how according to research, concern over insulin production, not well-researched and not well-backed
AA in pediatric pts-trophamine Allowing 364 ml/day vs. 233 ml/day when on fluid limit
Per discussion with cardiothoracic NP Dyana Crawford. Pt can be started on Similac 20kcal/oz.
Per rounds today: Initiating feeds with similac 20 PO with NG gavage as needed, CT to be pulled 30 minutes later if no chyle appearance, advancing to full feeds 24-48 hours. Changing formula to higher kcal/oz option once at fluid goal. Possibly transferring to Mt. Washington or home around Monday 6/21 depending on feed status and pain management.
Refer to article critique for more specifics. Barriers: hemodynamic instability, hypotension, hyperglycemia, fluid limits, mechanical ventilation, electrolyte derangements and impaired renal function Complications: acute renal failure, chylothorax and neurological dysfunction This pt population does not have a lot of research articles. Population very small, also ethics likely play into research options for randomizing treatment in peds pts. Found one RCT article involving an adjuvant therapy med, but it was in dogs, did not provide accurate picture of what has been observed in humans. Chose to place article first because it covers nutrition support in cardiac pt regardless of any complications developed. Not the best for research, but pertinent to initial recommendations for pt.
UMMC matches: IC not an option, predictive equations used but not always accurate, choice of EN and TPN based on benefits of each and adjusted for fluid limits.
Other topics: adjuvant medication therapies such as hypertension medications, corticosteroids, protein supplementation, electrolytes, and immunoglobulin; and surgical management for leaks not resolved in four weeks.
Chose this article to display results from an individual center’s practice and also to highlight the low occurrence of this condition and the low research available as a result. In the 9 years there were 18 pts so 2 per year, per Faith, that’s about the average at UMMC as well for pediatric pts.
Other articles: Cormack B, Wilson N, Finucane K, West T. Use of Monogen for Pediatric Postoperative Chylothorax. Annals of Thoracic Surgery. 2004;77:301-305. Retrospective review 1999-2001. 25 pt charts retrospectively reviewed: 18 had been given Monogen for enteral therapy and 6 had been given TPN, 1 excluded from review 2/2 to necessary change from EN to TPN. Use of EN and PN for nutrition support based more on location in hospital than actual indication. Facility initiated TPN for the ICU pts, but used EN for other pts. The other pts were switched to TPN only if they did not respond to use of EN for reduction in chylothorax. Of the EN pts, 78% responded to use of Monogen, the other pts were switched to TPN. Of the 4 original TPN pts, 2 responded with resolution of chylothorax, 2 required thoracic duct ligation. Nath D et al. Thoracic Duct Ligation for Persistent Chylothorax After Pediatric Cardiothoracic Surgery. Annals of Thoracic Surgery. 2009; 88:246-252. Retrospective review. Twenty post-op pts 1992-2007 under 18 years old diagnosed with chylothorax requiring TDL for treatment with 4 deaths (not from chylothorax). Attempted to non-surgically manage for approximately 17.5 days median. Pleural fluid tested for WBC, lympcytes, and TG content prior to diagnosis of chylothorax. No protocol during review time frame. Use of low-fat diet, NPO/TPN, somatostatin and corticosteroids for pre-op management. 18/20 pts (90%) had resolution with TDL. 2 had reoccurence of chyle leaks but with lower volumes, resolved with further NPO/TPN. 2 pts died.
Other 4: necrotizing pancreatitis, trauma pt with propfol infusion syndrome died before feeding, typhlitis in non-hodkins lymphoma, and trisomy 18 malrotation
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