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Development of consensus recommendations for the management of post-operative chylothorax in paediatric CHD

Published online by Cambridge University Press:  06 July 2022

Richard P. Lion*
Affiliation:
Department of Pediatrics, Division of Pediatric Cardiac Critical Care, University of Texas, Austin, TX, USA
Melissa M. Winder
Affiliation:
Department of Pediatrics, Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT, USA
Rambod Amirnovin
Affiliation:
Department of Pediatrics, Division of Pediatric Critical Care Medicine, Loma Linda University, Loma Linda, CA, USA
Kristi Fogg
Affiliation:
Department of Pediatrics, Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC, USA
Rebecca Bertrandt
Affiliation:
Department of Pediatrics, Division of Pediatric Critical Care, Children’s Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
Priya Bhaskar
Affiliation:
Department of Pediatrics, Division of Critical Care Medicine, UT Southwestern Medical Center, Dallas, TX, USA
Cameron Kasmai
Affiliation:
Department of Pediatrics, Division of Pediatric Critical Care, Children’s Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
Kathryn W Holmes
Affiliation:
Department of Pediatrics, Division of Pediatric Cardiology, OHSU Doernbecher Children’s Hospital, Portland, OR, USA
Rohin Moza
Affiliation:
Department of Pediatrics, Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT, USA
Piyagarnt Vichayavilas
Affiliation:
Department of Pediatrics, Division of Pediatric Cardiology, University of Colorado-Denver, Aurora, CO, USA
Erin E. Gordon
Affiliation:
Department of Pediatrics, Division of Pediatric Critical Care, University of Texas Southwestern, Dallas, TX, USA
Amiee Trauth
Affiliation:
Department of Nutrition Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
Megan Horsley
Affiliation:
Department of Nutrition Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
Deborah U. Frank
Affiliation:
Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Virginia, Charlottesville, VA, USA
Arabela Stock
Affiliation:
Department of Pediatrics, Division of Cardiac Critical Care, Johns Hopkins All Children’s, St Petersburg, FL, USA
Greg Adamson
Affiliation:
Department of Pediatrics, Division of Pediatric Cardiology, Stanford University/Lucile Packard Children’s Hospital, Palo Alto, CA, USA
Alissa Lyman
Affiliation:
Department of Pediatrics, Division of Pediatric Cardiology, OHSU Doernbecher Children’s Hospital, Portland, OR, USA
Tia Raymond
Affiliation:
Department of Pediatrics, Division of Cardiac Critical Care, Medical City Children’s Hospital, Dallas, TX, USA
Isaura Diaz
Affiliation:
Department of Pediatrics, Division of Critical Care Medicine, Monroe Carell Jr Children’s Hospital at Vanderbilt, Nashville, TN, USA
Alicia DeMarco
Affiliation:
Department of Pediatrics, Division of Anesthesiology/Critical Care Medicine, USC Keck School of Medicine, Los Angeles, CA, USA
Parthak Prodhan
Affiliation:
Department of Pediatrics, Division of Pediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, AR, USA
Michael Fundora
Affiliation:
Department of Pediatrics, Division of Cardiology, Children’s Healthcare of Aitlanta, Emory University School of Medicine, Atlanta, GA, USA
Alaa Aljiffry
Affiliation:
Department of Pediatrics, Division of Cardiology, Children’s Healthcare of Aitlanta, Emory University School of Medicine, Atlanta, GA, USA
Aaron G Dewitt
Affiliation:
Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Critical Care Medicine, The Children’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
Benjamin W. Kozyak
Affiliation:
Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Critical Care Medicine, The Children’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
Lawrence Greiten
Affiliation:
Department of Surgery, Division of Pediatric Cardiothoracic Surgery, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, 1 Children’s Way, Little Rock, AR, USA
Carly Scahill
Affiliation:
Department of Pediatrics, Division of Pediatric Cardiology, University of Colorado, Denver, Aurora, CO, USA
Jason Buckley
Affiliation:
Department of Pediatrics, Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC, USA
David K. Bailly
Affiliation:
Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA
*
Author for correspondence: Richard P. Lion, DO MPH, Dell Children’s Medical Center/Texas Center for Pediatric and Congenital Heart Disease, 4900 Mueller Blvd, 2 North CCU, Office 2H.005, Austin, TX78723, USA. Tel: +(203) 804–1968. Email: Richard.lion@austin.utexas.edu

Abstract

Objective:

A standardised multi-site approach to manage paediatric post-operative chylothorax does not exist and leads to unnecessary practice variation. The Chylothorax Work Group utilised the Pediatric Critical Care Consortium infrastructure to address this gap.

Methods:

Over 60 multi-disciplinary providers representing 22 centres convened virtually as a quality initiative to develop an algorithm to manage paediatric post-operative chylothorax. Agreement was objectively quantified for each recommendation in the algorithm by utilising an anonymous survey. “Consensus” was defined as ≥ 80% of responses as “agree” or “strongly agree” to a recommendation. In order to determine if the algorithm recommendations would be correctly interpreted in the clinical environment, we developed ex vivo simulations and surveyed patients who developed the algorithm and patients who did not.

Results:

The algorithm is intended for all children (<18 years of age) within 30 days of cardiac surgery. It contains rationale for 11 central chylothorax management recommendations; diagnostic criteria and evaluation, trial of fat-modified diet, stratification by volume of daily output, timing of first-line medical therapy for “low” and “high” volume patients, and timing and duration of fat-modified diet. All recommendations achieved “consensus” (agreement >80%) by the workgroup (range 81–100%). Ex vivo simulations demonstrated good understanding by developers (range 94–100%) and non-developers (73%–100%).

Conclusions:

The quality improvement effort represents the first multi-site algorithm for the management of paediatric post-operative chylothorax. The algorithm includes transparent and objective measures of agreement and understanding. Agreement to the algorithm recommendations was >80%, and overall understanding was 94%.

Type
Guidelines
Copyright
© The Author(s), 2022. Published by Cambridge University Press

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