Hostname: page-component-76fb5796d-9pm4c Total loading time: 0 Render date: 2024-04-25T11:11:49.424Z Has data issue: false hasContentIssue false
  • English
  • Français

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 Open the ORCID record for Richard P. Lion [Opens in a new window] ,
Melissa M. Winder Open the ORCID record for Melissa M. Winder [Opens in a new window] ,
Rambod Amirnovin ,
Kristi Fogg Open the ORCID record for Kristi Fogg [Opens in a new window] ,
Rebecca Bertrandt Open the ORCID record for Rebecca Bertrandt [Opens in a new window] ,
Priya Bhaskar ,
Cameron Kasmai ,
Kathryn W Holmes ,
Rohin Moza  and
Piyagarnt Vichayavilas
...Show all authors
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
Get access Rights & Permissions [Opens in a new window]

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%.

Keywords

Chylothoraxpaediatricguidelinesconsensuscardiac surgery
Type
Guidelines
Information
Cardiology in the Young , Volume 32 , Issue 8 , August 2022 , pp. 1202 - 1209
Check for updates
Copyright
© The Author(s), 2022. Published by Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Panthongviriyakul, C, Bines, J. Post-operative chylothorax in children: an evidence-based management algorithm. J Paediatr Child Health 2008; 44: 716–721.CrossRefGoogle ScholarPubMed
Mery, CM, Moffett, BS, Khan, MS, 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: 678–686.CrossRefGoogle ScholarPubMed
Schild, HH, Strassburg, CP, Welz, A, Kalff, J. Treatment options in patients with chylothorax. Dtsch Arztebl Int 2013; 110: 819–826.Google ScholarPubMed
Savla, JJ, Itkin, M, Rossano, JW, Dori, Y. Post-Operative Chylothorax in Patients With Congenital Heart Disease. J Am Coll Cardiol 2017; 69: 2410–2422.CrossRefGoogle ScholarPubMed
Church, JT, Antunez, AG, Dean, A, et al. Evidence-based management of chylothorax in infants. J Pediatr Surg 2017; 52: 907–912.CrossRefGoogle ScholarPubMed
Tutor, JD. Chylothorax in infants and children. Pediatrics 2014; 133: 722–733.CrossRefGoogle ScholarPubMed
Buckley, JR, Graham, EM, Gaies, M, et al. Clinical epidemiology and centre variation in chylothorax rates after cardiac surgery in children: a report from the Pediatric Cardiac Critical Care Consortium. Cardiol Young 2017: 1678–1685.CrossRefGoogle ScholarPubMed
Czobor, NR, Roth, G, Prodan, Z, et al. Chylothorax after pediatric cardiac surgery complicates short-term but not long-term outcomes-a propensity matched analysis. J Thorac Dis 2017; 9: 2466–2475.CrossRefGoogle Scholar
Winder, MM, Eckhauser, AW, Delgado-Corcoran, C, Smout, RJ, Marietta, J, Bailly, DK. A protocol to decrease postoperative chylous effusion duration in children. Cardiol Young 2018; 28: 816–825.CrossRefGoogle ScholarPubMed
Yeh, J, Brown, ER, Kellogg, KA, et al. Utility of a clinical practice guideline in treatment of chylothorax in the postoperative congenital heart patient. Ann Thorac Surg 2013; 96: 930–936.CrossRefGoogle ScholarPubMed
Shin, YR, Lee, H, Park, YH, Park, HK. Chylothorax after surgery for congenital cardiac disease: a prevention and management protocol. Korean J Thorac Cardiovasc Surg 2020; 53: 41–48.CrossRefGoogle ScholarPubMed
Buttiker, V, Fanconi, S, Burger, R. Chylothorax in Children: guidelines for Diagnosis and Management. Chest 1999; 116: 682–687.CrossRefGoogle ScholarPubMed
Milonakis, M, Chatzis, AC, Giannopoulos, NM, et al. Etiology and management of chylothorax following pediatric heart surgery. J Card Surg 2009; 24: 369–373.CrossRefGoogle ScholarPubMed
Beghetti, M, La Scala, G, Belli, D, Bugmann, P, Kalangos, A, Le Coultre, C. Etiology and management of pediatric chylothorax. J Pediatr 2000; 136: 653–658.CrossRefGoogle ScholarPubMed
Densupsoontorn, N, Jirapinyo, P, Wongarn, R, et al. Management of chylothorax and chylopericardium in pediatric patients: experiences at Siriraj Hospital, Bangkok. Asia Pac J Clin Nutr 2005; 14: 182–187.Google ScholarPubMed
Matsuo, S, Takahashi, G, Konishi, A, Sai, S. Management of refractory chylothorax after pediatric cardiovascular surgery. Pediatr Cardiol 2013; 34: 1094–1099.CrossRefGoogle ScholarPubMed
Pego-Fernandes, P, Nascimbem, M, Ranzani, O, Shimoda, M, Monteiro, R, Jatene, F. Video-assisted thoracoscopy as an option in the surgical treatment of chylothorax after cardiac surgery in children. J Bras Pneumol 2011; 37: 28–35.CrossRefGoogle ScholarPubMed
Hermon, M, Tenner, E, Burda, G, Strohmaier, W, Schlager, G, Golej, J. Chylothorax and Chylous-Like Diseases in Children: clinical Management. Front Pediatr 2019; 7: 258.CrossRefGoogle ScholarPubMed
Furlong-Dillard, JM, Miller, BJ, Sward, KA, et al. The association between feeding protocol compliance and weight gain following high-risk neonatal cardiac surgery. Cardiol Young 2019; 29: 594–601.CrossRefGoogle ScholarPubMed
Soto-Martinez, M, Massie, J. Chylothorax: diagnosis and management in children. Paediatr Respir Rev 2009; 10: 199–207.CrossRefGoogle ScholarPubMed
McGrath, EE, Blades, Z, Anderson, PB. Chylothorax: aetiology, diagnosis and therapeutic options. Respir Med 2010; 104: 1–8.CrossRefGoogle ScholarPubMed
Winder, MM. Five years of chylothorax data from pediatric patients following cardiac surgery at Primary Children’s Hospital. Presented at Chylothorax Work Group Meeting: primary Children’s Hospital; 2021.Google Scholar
Chan, EH, Russell, JL, Williams, WG, Van Arsdell, GS, Coles, JG, McCrindle, BW. Postoperative chylothorax after cardiothoracic surgery in children. Ann Thorac Surg 2005; 80: 1864–1870.CrossRefGoogle ScholarPubMed
Nath, DS, Savla, J, Khemani, RG, Nussbaum, DP, Greene, CL, Wells, WJ. Thoracic duct ligation for persistent chylothorax after pediatric cardiothoracic surgery. Ann Thorac Surg 2009; 88: 246–251.CrossRefGoogle ScholarPubMed
McCulloch, MA, Conaway, MR, Haizlip, JA, Buck, ML, Bovbjerg, VE, Hoke, TR. Postoperative chylothorax development is associated with increased incidence and risk profile for central venous thromboses. Pediatr Cardiol 2008; 29: 556–561.CrossRefGoogle ScholarPubMed
Bauman, ME, Moher, C, Bruce, AK, Kuhle, S, Kaur, S, Massicotte, MP. Chylothorax in children with congenital heart disease: incidence of thrombosis. Thromb Res 2013; 132: e83–e85.CrossRefGoogle ScholarPubMed
Hargus, EP, Carson, SD, McGrath, RL, Wolfe, RR, Clarke, DR. Chylothorax and chylopericardial tamponade following Blalock-Taussig anastomosis. The Journal of Thoracic and Cardiovascular Surgery 1978; 75: 642–645.CrossRefGoogle ScholarPubMed
Calkins, KL, Venick, RS, Devaskar, SU. Complications associated with parenteral nutrition in the neonate. Clin Perinatol 2014; 41: 331–345.CrossRefGoogle ScholarPubMed
Hartman, C, Shamir, R, Simchowitz, V, Lohner, S, Cai, W, Decsi, T. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: complications. Clin Nutr 2018; 37: 2418–2429.CrossRefGoogle ScholarPubMed
Hill, JO, Peters, JC, Swift, LL, et al. Changes in blood lipids during six days of overfeeding with medium or long chain triglycerides. J Lipid Res 1990; 31: 407–416.CrossRefGoogle ScholarPubMed
Anez-Bustillos, L, Dao, DT, Fell, GL, et al. Redefining essential fatty acids in the era of novel intravenous lipid emulsions. Clin Nutr 2018; 37: 784–789.CrossRefGoogle ScholarPubMed
Kocel, SL, Russell, J, O’Connor, DL. Fat-modified breast milk resolves chylous pleural effusion in infants with postsurgical chylothorax but is associated with slow growth. J Parenter Enteral Nutr 2016; 40: 543–551.CrossRefGoogle Scholar
Fogg, KL, DellaValle, DM, Buckley, JR, Graham, EM, Zyblewski, SC. Feasibility and efficacy of defatted human milk in the treatment for chylothorax after cardiac surgery in infants. Pediatr Cardiol 2016; 37: 1072–1077.CrossRefGoogle ScholarPubMed
Drewniak, MA, Lyon, AW, Fenton, TR. Evaluation of fat separation and removal methods to prepare low-fat breast milk for fat-intolerant neonates with chylothorax. Nutr Clin Pract 2013; 28: 599–602.CrossRefGoogle ScholarPubMed
Neumann, L, Springer, T, Nieschke, K, Kostelka, M, Dahnert, I. ChyloBEST: chylothorax in Infants and Nutrition with Low-Fat Breast Milk. Pediatr Cardiol 2020; 41: 108–113.CrossRefGoogle ScholarPubMed
Sunstrom, RE, Muralidaran, A, Gerrah, R, et al. A defined management strategy improves early outcomes after the Fontan procedure: the Portland protocol. Ann Thorac Surg 2015; 99: 148–155.CrossRefGoogle ScholarPubMed
Pike, NA, Okuhara, CA, Toyama, J, Gross, BP, Wells, WJ, Starnes, VA. Reduced pleural drainage, length of stay, and readmissions using a modified Fontan management protocol. J Thorac Cardiovasc Surg 2015; 150: 481–487.CrossRefGoogle ScholarPubMed
Marino, LV, Bell, KL, Woodgate, J, British Dietetic Association Paediatric Cardiology Interest Group, Doolan, A. An international survey of the nutrition management of chylothorax: a time for change. Cardiol Young 2019; 29: 1127–1136.CrossRefGoogle Scholar
Mehta, NM, Compher, C. A.S.P.E.N. Clinical guidelines: nutrition support of the critically Ill child. J Parenter Enteral Nutr 2009; 33: 260–276.CrossRefGoogle Scholar
Mehta, NM, Skillman, HE, Irving, SY, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. J Parenter Enteral Nutr 2017; 41: 706–742.CrossRefGoogle ScholarPubMed
Fell, GL, Nandivada, P, Gura, KM, Puder, M. Intravenous lipid emulsions in parenteral nutrition. Adv Nutr 2015; 6: 600–610.CrossRefGoogle ScholarPubMed
McCray, S, Parrish, C. Nutritional management of Chyle leaks: an update. Practical Gastro 2011: 12–32.Google Scholar
Biewer, ES, Zurn, C, Arnold, R, 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.CrossRefGoogle ScholarPubMed
Bender, B, Murthy, V, Chamberlain, RS. The changing management of chylothorax in the modern era. Eur J Cardiothorac Surg 2016; 49: 18–24.CrossRefGoogle ScholarPubMed
Winder, MM, Vijayarajah, S, Reeder, RW. Successfully reducing fat-modified diet duration for treating postoperative chylothorax in children. Ann Thorac Surg 2021; epub ahead of print.CrossRefGoogle Scholar
Supplementary material: File

Lion et al. supplementary material

Table S3
Download Lion et al. supplementary material(File)
File 54.1 KB