Efficacy of nil per oral,total parenteral nutrition,milrinone and non-suction chest tube drainage-based management for chylothorax following pediatric cardiac surgery

Abstract

Objective

A single centre experience with chylothorax in post cardiac surgical patients.

Methods

Retrospective review.

Results

Chylothorax developed in 55 out of 873 operated patients (6.3%). Median age of the chylothorax cohort was 95 days (range 1–995). Neonates constituted 36% and 49% were infants. Group-1(35 patients-treated during the years 2011–2015) included those who were managed with low fat diet initially with other standard measures including steroid, octreotide, pleurodesis, lymphangiogram or thoracic duct ligation whenever required.Group-2 (20 patients, treated between year 2016–2018) were managed with nil per oral, total parenteral nutrition, extended use of milrinone and no use of chest tube suction with other above standard measures when required.Group-1 and group-2 were comparable in terms of their age and weight (p > 0.05).We observed lower volume of chest drainage, shorter intubation time, length of intensive care stay and hospital stay in group-2 compared to group-1 though they were statistically not significant (p > 0.05). Occurrence of massive chylothorax (>20 ml/kg/day) in group-1 was significantly higher [18 patients (51%) in group-1 vs 4 patients in group-2 (20%) (Chi-square 5.25, p = 0.02)]. In hospital mortality in group-1 was higher compared to group-2 (5/35 = 14.5% vs 1/20 = 5%), however, it was statistically not significant [risk ratio 2.86; 95% CI 0.36, 22.77; p = 0.59)]. Acute kidney injury was observed in about 25% of patients who had chylothorax. A higher mortality was observed in patients with chylothorax who had acute kidney injury [5/14 (35%)] compared to those who did not have acute kidney injury [1/41 (2.4%)] (Chi-square 11.89, p = 0.001)].

Summary

In a heterogenous cohort of post-cardiac surgical patients who developed chylothorax, our suggested new regime (nil per oral, parenteral nutrition, extended use of milrinone and no suction applied to the chest drains) contributed to reduce the frequency of massive chylothorax occurrence significantly.

Keywords

chylothorax pediatric cardiac surgery nil per oral total parenteral nutrition milrinone chest tube suction high-output chylothorax

Get full access to this article

View all access options for this article.

References

Mery

Moffett

Khan

, et al. Incidence and treatment of chylothorax after cardiac surgery in children: analysis of a large multi-institution database. J Thorac Cardiovasc Surg 2014; 147: 678–86.e1.

Chan

Russell

Williams

, et al. Postoperative chylothorax after cardiothoracic surgery in children. Ann Thorac Surg 2005; 80: 1864–1870.

Biewer

Zurn

Arnold

, et al. Chylothorax after surgery on congenital heart disease in newborns and infants-risk factors and efficacy of MCT-diet. J Cardiothorac Surg 2010; 5: 127.

Haines

Walsh

Fletcher

, et al. Chylothorax development in infants and children in the UK. Arch Dis Child 2014; 99: 724–730.

Borasino

Diaz

Masri

, et al. Central venous lines are a risk factor for chylothorax in infants after cardiac surgery. World J Pediatr Congenit Heart Surg 2014; 5: 522–526.

Beghetti

La Scala

Belli

, et al. Etiology and management of pediatric chylothorax. J Pediatr 2000; 136: 653–658.

Zuluaga

. Chylothorax after surgery for congenital heart disease. Curr Opin Pediatr 2012; 24: 291–294.

Shin

Lee

Park

, et al. Chylothorax after surgery for congenital cardiac disease: a prevention and management protocol. Korean J Thorac Cardiovasc Surg 2020; 53: 41–48.

Buttiker

Fanconi

Burger

. Chylothorax in children: guidelines for diagnosis and management. Chest 1999; 116: 682–687.

10.

Agrawal

Doelken

Sahn

. Pleural fluid analysis in chylous pleural effusion. Chest 2008; 133: 1436–1441.

11.

Robinson . The management of chylothorax. Ann Thorac Surg 1985; 39: 90–95.

12.

Paes

Powell

. Chylothorax: an update. Br J Hosp Med 1994; 51: 482–490.

13.

Nair

Petko

Hayward

. Aetiology and management of chylothorax in adults. Eur J Cardiothorac Surg 2007; 32: 362–369.

14.

Cleveland

Zook

Harvey

, et al. Massive chylothorax in small babies. J Pediatr Surg 2009; 44: 546–550.

15.

Matsuo

Takahashi

Konishi

, et al. Management of refractory chylothorax after pediatric cardiovascular surgery. Pediatr Cardiol 2013; 34: 1094–1099.

16.

Bender

Murthy

Chamberlain

. The changing management of chylothorax in the modern era. Eur J Cardiothorac Surg 2016; 49: 18–24.

17.

Le Nué

Molinaro

Gomes-Ferreira

. Surgical management of congenital chylothorax in children. Eur J Pediatr Surg 2010; 20: 307–311.

18.

Nath

Savla

Khemani

, et al. Thoracic duct ligation for persistent chylothorax after pediatric cardiothoracic surgery. Ann Thorac Surg 2009; 88: 246–252.

19.

Miao

Zhang

, et al. Incidence and management of chylothorax after esophagectomy. Thorac Cancer 2015; 6: 354–358.

20.

Panthongviriyakul

Bines

. Post-operative chylothorax in children: an evidence-based management algorithm. J Paediatr Child Health 2008; 44: 716–721.

21.

Nguyen

Shum-Tim

Dobell

ARC

, et al. The management of chylothorax/chylopericardium following pediatric cardiac surgery: a 10-year experience. J. Card. Surg 1995; 10: 302–308.

22.

Wilson

Finucane

, et al. Use of monogen for pediatric postoperative chylothorax. Ann. Thorac. Surg 2004; 77: 301–305.

23.

Bond

Guzzetta

Snyder

, et al. Management of pediatric postoperative chylothorax. Ann. Thorac. Surg 1993; 56: 469–473.

24.

Stern

Weil

Genz

, et al. Captopril in children with dilated cardiomyopathy: acute and long-term effects in a prospective study of hemodynamic and hormonal effects. Pediatr. Cardiol 1990; 11: 22–28.

25.

Dibner-Dunlap

Smith

Kinugawa

, et al. Enalaprilat augments arterial and cardiopulmonary baroreflex control of sympathetic nerve activity in patients with heart failure. J Am Coll Cardiol 1996; 27: 358–364.

26.

Sunstrom

Muralidaran

Gerrah

, et al. A defined management strategy improves early outcomes after the Fontan procedure: the PORTLAND protocol. Ann Thorac Surg 2015; 99: P148–P155.

27.

Lijkendijk

Neckelmann

Licht

. External suction and fluid output in chest drains after lobectomy: a randomized. Clin Trial Ann Thorac Surg 2018; 105: 393–398.

28.

Miserocchi

Beretta

Rivolta

. Respiratory mechanics and fluid dynamics after lung resection surgery. Thorac Surg Clin 2010; 20: 345–357.

29.

Dango

Sienel

Passlick

, et al. Impact of chest tube clearance on postoperative morbidity after thoracotomy: results of a prospective, randomised trial. Eur J Cardiothorac Surg 2010; 37: 51–55.

30.

Gocyk

Kużdżał

Włodarczyk

, et al. Comparison of suction versus nonsuction drainage after lung resections: a prospective randomized trial. Ann Thorac Surg 2016; 102: 1119–1124.