Chylothorax

ChylothoraxDawn Reed

Little Miss KH Female

Birth/Admit date: Oct. 14, 2013

Birth weight: 3.6 kg (7 lbs, 14 oz)

Length: 51 cm (20 in)

Pre-diagnosed with aortic coarctation

Parents were able to prepare for hospital stay and plan on delivering at U of U Hospital

Family Social History: Parents were married

3 siblings

LDS

Wendover, UT

Time Spent at Primary Children’s Hospital

Cardiac Defects: Aortic coarctation VSD, ASD AV block and pacemaker

Chylothorax IV infiltrate

Cardiac Defects

• Aortic coarctation

• VSD

• ASD

• AV block

• Pacemaker

Coarctation

ASD

Operation Timetable

• Aortic arch augmentation• Ventricular septal defect closure• Partial atrial septal defect closure

10/17/13

• Delayed sternal closure10/19/13

• Placement of dual-chamber, bipolar epicardial pacemaker10/28/13

• KH diagnosed with Chylothorax10/22/13

Lymphatic System

Functions: Fluid balance: Removal of

interstitial fluid from tissues

Fat absorption: Absorbs fats from the intestine and transports into the blood flow

Immunity and defense: Filters microorganisms and foreign substances, transports WBCs

Chylothorax

Pleural effusions Presence of lymphatic

fluid in the pleural space Cause: leak in the

thoracic duct OR lymphatic

abnormalities

Trauma or damage to the thoracic duct

Chyle: Composed of

chylomicrons & lymph

Purpose: absorption and transport of LCT in the intestines

Responsible for absorption of fat-soluble vitamins

High losses are of great nutritional concern

Diagnosis

Signs and Symptoms Cough

Dyspnea

Chest discomfort

Pain with breathing

Dependent upon size of chylothorax

Diagnosis Chest X-ray confirms

presence of pleural fluid

Analyze the fluid Elevated lymphocytes

Elevated triglycerides

High total protein content

Normal

Pleural Effusion

Management and Treatment

Medical Management Includes the use of:

Somatostatins

Octreotide

Reduces intestinal secretions and inhibits lymph excretion

Pleural drainage (chest tubes)

Watch for decreased output

Nutrition Management

Very low-fat diet

Majority of fats from MCTs

Gut rest

Parenteral nutrition

Trial feeds (low-fat or MCT enriched) decreased output?

Feeds:

Skimmed breast milk enriched with MCT, protein, source of EFA

Specialty formulas

Monitoring and Resolution

Monitor: Albumin Electrolytes Fat-soluble vitamins

Usually resolves without extensive treatment

Other Events While at Hospital

Chylous drainage from chest tubes (3) was variable.

Chest tubes removed on 11/1

Respiratory support

10/22 – Development of small ileus Stop and restart feeds

10/22 – IV infiltrate with arginine chloride on left hand

KH was followed by multiple disciplines throughout her stay: Wound care, Plastics for IV infiltrate

ST – worked on normal oral cues

PT

OT

Nutrition Care Process: Anthros

Date Grams Pounds

10/14 3600 7.94

10/28 3670 8.09

10/30 3710 8.18

Weight 75%ile Length 75%ile Appropriate weight

gain

Weight:

Length: 51 cm

Biochemical

Hematocrit consistently low

WBC variable, occasional high

WNL: Triglycerides

Albumin

RFP

Creatinine

Electrolytes

Medications

Acetaminophen Bacitracin Omeprazole Oxycodone Milrinone

Octreotide Dopamine Prevacid Lasix PGEs

Estimated Needs

Type Kcals/kg Protein (gm/kg) Fluid (ml/kg)

Acute 89 2.5-3.5 100

Parenteral 95-102 2.5-3.5 100

Growth 110-120 2.5-3 100

*Based on ABW

Diagnoses

Increased nutrient needs r/t physiological causes increasing nutrient needs d/t disease/condition (CHD) AEB need for close nutrition monitoring, nutrition support and specialized formula.

Altered GI function r/t CHD, PGEs AEB need for TPN and trophic feeds.

Interventions, Goals, Monitoring, and Evaluation 10/15: 9ml Q 3hrs breast milk and 20kcal/oz formula

10/15: Parenteral formula/solution

10/22: 24kcal/oz Enfaport @ 18ml/hr

10/30: 27kcal/oz Enfaport @ 19ml/hr

Goal: Provide age/condition appropriate nutrition to regain birth weight by 10-14 days, then gain 25-35 gm/d thereafter. 24kcal/oz Enfaport @ 22ml/hr

27kcal/oz Enfaport @ 19ml/hr

Monitoring and Evaluation: Growth

Tolerance

Labs

Conclusion

16 day old female with aortic coarctation, developed a chylothorax

At goal on feeds of 27kcal Enfaport Prognosis: Good Discharged 11/3 to home with parents Home formula orders:

27kcal/oz Enfaport, 60ml Q 3hrs until 12/3/13

Change to Similac 27 kcal/oz

References

Venes D. Taber’s Cyclopedic Medical Dictionary. Philadelphia PA: F.A. Davis Company; 2005.

Porter RS, Kaplan JL. The Merck Manual. Whitehouse Station NJ: Merck Sharp and Dohme Corp.; 2011.

Samour PQ, King K. Pediatric Nutrition. Sadbury, Ma: Jones and Bartlett Learning; 2012.

Tate SS. Anatomy and Physiology. New York NY: McGraw-Hill; 2008.