Hostname: page-component-586b7cd67f-gb8f7 Total loading time: 0 Render date: 2024-11-23T04:53:14.514Z Has data issue: false hasContentIssue false
  • English
  • Français

A protocol to decrease postoperative chylous effusion duration in children

Published online by Cambridge University Press:  25 April 2018

Melissa M. Winder ,
Aaron W. Eckhauser ,
Claudia Delgado-Corcoran ,
Randall J. Smout ,
Jennifer Marietta  and
David K. Bailly
Melissa M. Winder*
Affiliation:
Department of Pediatric Critical Care, Primary Children’s Hospital, Salt Lake City, UT, USA
Aaron W. Eckhauser
Affiliation:
Division of Pediatric Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
Claudia Delgado-Corcoran
Affiliation:
Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA
Randall J. Smout
Affiliation:
Continuous Improvement, Primary Children’s Hospital, Salt Lake City, UT, USA
Jennifer Marietta
Affiliation:
Heart Center, Primary Children’s Hospital, Salt Lake City, UT, USA
David K. Bailly
Affiliation:
Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA
*
Author for correspondence: M. M. Winder, CPNP-AC, Department of Pediatric Critical Care, Primary Children’s Hospital, 100 N Mario Capecchi Dr, Salt Lake City, UT 84113, USA. Tel: 801 647 1680; Fax: 801 662 2412; E-mail: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective

Our primary goal was to decrease time to resolution of postoperative chylothorax as demonstrated by total days of chest tube utilisation through development and implementation of a management protocol.

Methods

A chylothorax management protocol was implemented as a quality improvement project at a tertiary-care paediatric hospital in July, 2015. Retrospective analysis was completed on patients aged 0–17 years diagnosed with chylothorax within 30 days of cardiac surgery in a pre-protocol cohort (February, 2014 to June, 2015, n=20) and a post-protocol cohort (July, 2015 to March, 2016, n=22).

Measurements and results

Patient characteristics were similar before and after protocol implementation. Duration of mechanical ventilation and cardiac ICU and hospital lengths of stay were unchanged between cohorts. Following protocol implementation, total duration of chest tube utilisation decreased from 12 to 7 days (p=0.047) with a decrease in maximum days of chest tube utilisation from 44 to 13 days. Duration of medium-chain triglyceride feeds decreased from 42 days to 31 days (p=0.01). In total, three patients in the post-protocol cohort underwent additional surgical procedures to treat chylothorax with subsequent resolution of chylothorax within 24 hours. There were no chest tube re-insertions or re-admissions related to chylothorax in either the pre- or post-protocol cohorts. Protocol compliance was 81%.

Conclusions

Adoption of a chylothorax management protocol is feasible, and in our small cohort of patients implementation led to a significant decrease in the duration of chest tube utilisation, while eliminating practice variability among providers.

Keywords

Paediatricsheart defectschylothoraxclinical protocolsquality improvement
Type
Original Articles
Information
Cardiology in the Young , Volume 28 , Issue 6 , June 2018 , pp. 816 - 825
Check for updates
Copyright
© Cambridge University Press 2018 

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

1. 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.Google Scholar
2. Buckley, J, 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; 27: 1–8.Google Scholar
3. 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 ScholarPubMed
4. Beghetti, M, La Scala, G, Belli, D, et al. Etiology and management of pediatric chylothorax. J Pediatr 2000; 136: 653–658.Google Scholar
5. 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 Card Surg 2010; 5: 127–133.Google Scholar
6. Chan, EH, Russell, JL, Williams, WG, et al. Postoperative chylothorax after cardiothoracic surgery in children. Ann Thorac Surg 2005; 80: 1864–1871.Google Scholar
7. Milonakis, M, Chatzis, AC, Giannopoulos, NM, et al. Etiology and management of chylothorax following pediatric heart surgery. J Card Surg 2009; 24: 369–373.Google Scholar
8. Panthongviriyakul, C, Bines, JE. Post-operative chylothorax in children: an evidence-based management algorithm. J Paediatr Child Health 2008; 44: 716–721.Google Scholar
9. Tutor, J. Chylothorax in infants and children. Pediatrics 2014; 133: 722–733.Google Scholar
10. 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.Google Scholar
11. Day, T, Zannino, D, Golshevsky, D, et al. Chylothorax following paediatric cardiac surgery: a case-control study. Cardiol Young 2017; 28: 1–7.Google Scholar
12. Ismail, SR, Kabbani, MS, Najm, HK, et al. Impact of chylothorax on the early post operative outcome after pediatric cardiovascular surgery. J Saudi Heart Assoc 2014; 26: 87–92.Google Scholar
13. McCray, S, Parrish, CR. Nutritional management of chyle leaks: an update. Pract Gastr 2011; 94: 12–32.Google Scholar
14. Nath, DS, Savla, J, Khemani, RG, et al. Thoracic duct ligation for persistent chylothorax after pediatric cardiothoracic surgery. Ann Thorac Surg 2009; 88: 246–251.Google Scholar
15. Densupsoontorn, N, Jirapinyo, P, Tirapongporn, H, et al. Fat-soluble vitamins and plasma and erythrocyte membrane fatty acids in chylothorax pediatric patients receiving a medium-chain triglyceride-rich diet. J Clin Biochem Nutr 2014; 55: 174–177.Google Scholar
16. Caverly, L, Rausch, CM, da Cruz, E, Kaufman, J. Octreotide treatment of chylothorax in pediatric patients following cardiothoracic surgery. Congenit Heart Dis 2010; 5: 573–578.Google Scholar
17. White, SC, Seckeler, MD, McCulloch, MA, et al. Patients with single ventricle anatomy may respond better to octreotide therapy for chylothorax after congenital heart surgery. J Card Surg 2014; 29: 259–264.Google Scholar
18. Matsuo, S, Takahashi, G, Konishi, A, et al. Management of refractory chylothorax after pediatric cardiovascular surgery. Pediatr Cardiol 2013; 34: 1094–1099.Google Scholar
19. Chang, AC, Atz, AM, Wernovsky, G, et al. Milrinone: systemic and pulmonary hemodynamic effects in neonates after cardiac surgery. Crit Care Med 1995; 23: 1907–1914.Google Scholar
Supplementary material: File

Winder et al. supplementary material

Winder et al. supplementary material 1

Download Winder et al. supplementary material(File)
File 47.3 KB