CG: Chylothorax After Abdominal Aortic Aneurysm (AAA) Repair - PowerPoint PPT Presentation


Title: CG: Chylothorax After Abdominal Aortic Aneurysm (AAA) Repair


1
CGChylothorax After Abdominal Aortic Aneurysm
(AAA) Repair
  • By Anna Bondy, Dietetic Intern
  • June 6th, 2012

2
Background Chylothorax5
  • Chyle is a component of lymph that originates
    from the GI tract that contains chylomicrons,
    fat, protein, electrolytes and lymphocytes
  • 1.5-4 L of chyle flows through the thoracic duct
    every day2
  • Lymph also transports Long-chain Triglycerides
    (LCTs) and fat-soluble vitamins
  • A chylothorax is caused by a blockage or
    disruption of the thoracic duct or the
    surrounding lymph system2

3
Background Chylothorax
  • Most dietary fat is in the form of LCTs
  • LCTs are digested by pancreatic enzymes in the
    small bowel, and emulsified by bile salts before
    being absorbed and converted to chylomicrons
  • Chylomicrons enter the lymphatic system through
    lacteals found in the villi
  • 70 of ingested fat will pass through the
    lymphatic system
  • High intake of LCTs increases chyle flow,
    decreased intake of LCTs decreases chyle flow
  • This is the basis for substituting LCTs with
    Medium-chain triglycerides (MCTs) as part of the
    MNT for this condition2

4
(No Transcript)
5
Causes of Chyle Leaks5,6
  • Primary
  • Congenital lymphangiectasia
  • Secondary
  • Lymphoma
  • Penetrating Trauma
  • Lymphoangioleiomyomatosis (LAM)
  • Cirrhosis
  • Tuberculosis
  • Idiopathic
  • Congenital Chylothorax
  • Post operative complications
  • Radical Neck Dissection
  • Cardiothoracic surgery
  • Esophagectomy

6
Causes of Chyle Leaks5,6
  • Pulmonary resection
  • Abdominal aortic aneurysm repair
  • Pancreatic resections
  • According to Allahan, et al, the overall
    incidence of chylothorax in thoracic AAA repair
    patients is 0.41

7
Diagnosis of Chyle Leak
  • Signs Symptoms
  • New pleural effusion, dypsnea1
  • Drainage appears milky or white in about 44 of
    cases (can be clear or reddish-brown)4
  • Biochemical Tests
  • Pleural fluid triglyceride level gt 110 mg/dL
  • Pleural fluid triglyceride level 50 110 mg/dL
    with the presence of chylomicrons in the
    lipoprotein analysis
  • Pleural fluid triglyceride level may be lt 50 if
    patient is fasting, especially after surgery
  • Maldonado, et al 2.7 of patients with
    chylothorax has TG lt 50 due to fasting4

8
Treatment Options
  • Conservative Management
  • Chest tube placement for drainage of chylous
    effusion and use of Medical Nutrition Therapy
  • Pharmacology
  • Octreotide therapy is thought to decrease chyle
    flow, and has been used been successfully in
    neonates with chylothorax
  • Dosing of 50 200 mcg TID5, adjusted for renal
    impairment and liver disease
  • Surgical repair (Thoracic/Lymphatic Duct
    Ligation)
  • Indicated for nutritionally depleted patients,
    especially patients with esophageal disease11
  • Indicated in adults with gt 1500 ml/d of CT output
    x5 days OR children with gt 100 ml age x5 days
  • Indicated if chyle output does not decrease over
    a two week period9

9
From Valentine (1992)
10
Nutrition Implications
  • The medical nutrition therapy for chyle leak
    focuses on restriction of dietary long-chain
    triglycerides while correcting other nutrient
    deficiencies
  • A PO diet low in long-chain triglycerides can be
    very restrictive diet and put patients at risk
    for malnutrition
  • Nutritional deficiencies of calories, fat,
    protein, and fat-soluble vitamins can result from
    the loss of chyle
  • Chyle has 200 calories per liter, 30 g protein
    per liter and contains fat-soluble vitamins
  • A diet without sufficient essential fatty acids
    (EFA) can result in poor wound healing2,5
  • Chyle leaks can lead to immunosuppression, which
    puts patients at higher risk of infection

11
Medical Nutrition Therapy
  • Goals of MNT
  • 1) Decrease production of chyle fluid in order to
    avoid aggravating the effusion, ascites, or chest
    tube drainage
  • 2) Replace fluid and electrolytes
  • 3) Maintain or replete nutritional status and
    prevent malnutrition5
  • Low-fat or fat-free oral diet
  • Fat-free oral supplements, such as Resource
    Breeze or Enlive
  • MCT Oil Supplementation (4-5 Tablespoons of MCT
    oil/day)
  • May cause diarrhea or GI distress
  • Additional Supplementation
  • Essential Fatty Acids (no EFAs in MCT Oil),
    Multivitamin/ Fat-soluble vitamins, Protein
  • Specialized enteral formula
  • Vivonex or other low-fat, high MCT formula
  • Parenteral nutrition (IV lipids do not contribute
    to chyle flow)

12
(No Transcript)
13
Formula Vivonex RTF _at_95 ml/hr Vivonex RTF (250 ml) Peptamen 1.5 (250 ml) Vital 1.5 (250 ml) Vital HN (300 ml) - Powder
Calories 2090 250 375 356 300
Total Fat 24.2 g 2.9 g 14 g 13.5 g 3.3 g
Cal from Fat 10 10 33 33 9.5
MCT 40 9.7 g 146 ml 40 1.2 g 18 ml 70 9.8 g 147 ml 47.5 6.4 g 96 ml 45 1.5 g 23 ml
Price 0.032/ kcal (6000 kcal/191 case) 0.019/ kcal (9000 kcal/170 case) 0.020/ kcal 8532 kcal/172 case) 0.020/ kcal (7200 kcal/146 case)
MCT Oil contains 8.3 calories per gram (1 Tb 15
mL 115 kcal).
14
For chest tube output gt 500 use elemental
formula, for output lt500, semi-elemental formula
may be used.5 Supplement Oral Low-Fat Diet or
Clear Liquid Diet with MCT Oil, Fat Free
Supplements and monitor for nutritional
deficiencies.10
Discharge to Home on a Low-fat Diet with
Outpatient follow-up
15
Meet Patient CG
16
Reasons for Patient Selection
  • Complex Medical History
  • Vascular Disease
  • Stage IV Wounds
  • Renal Insufficiency
  • New Diagnosis of Chylothorax
  • Resolution with appropriate Medical Nutrition
    Therapy

17
General Issues
  • Patient Name CG
  • Age 68 years old
  • Gender Male
  • Admitted 4/10/12 from OSH
  • Intake Triage
  • ? Home TF
  • ? Stage III/IV Pressure Ulcer
  • ? NPO with TF at home

18
General Issues
  • Significant PMH HTN, CAD, severe PVD, HLD, CHF,
    DVT, carotid stenosis, retroperitoneal fibrosis,
    hydronephrosis, infected AAA, TIA, hearing loss,
    ischemic heart disease, L pleural effusion, L
    thoracotomy, hernia, stopped HD 3/2012, HCD, PNA
  • Significant PSH (gt5 years ) aortobifemoral
    artery bypass grafting, endograft repair of a
    proximal pseudoaneurysm, right graft limb
    thrombosis s/p femoral-femoral bypass graft.
    Graft infection s/p right left axillopopliteal
    artery bypass with removal of infected graft in
    LLE RLE.

19
General Issues
  • Significant PSH (2007-2011) Multiple graft
    infections leading to retroperitoneal fibrosis
    and multiple bilateral ureteral stent
    replacements, non-operative aortic aneurysm
  • Social History Wife is major source of support,
    son also participates in decision-making, patient
    mostly nonverbal

20
Recent Admissions
  • Admission 1/3/12-3/1/12
  • 12/24/2011 MRI Thoracic Lumbar Spine
    thrombosed abdominal aortic aneurysm, with
    extension of the aneurysm sac into the L1 and L2
    vertebral bodies.
  • 1/3/2012 Right axillary popliteal graft bypass
    to left axillary popliteal bypass graft with
    excision of infected aortic thoracoabdominal
    aneurysm with left renal artery bypass,
    debridement of anterior lumbar spine
  • 1/3/2012-1/20/2012 SICU Stay complicated by
    respiratory and renal failure
  • 1/21/12 Tracheostomy, 6 Shiley

21
Recent Admissions
  • Admission 3/8/12-4/4/12
  • Worsening sacral decubitis ulcer, open
    thoracoabdominal surgical site
  • Significant Nutritional History
  • 2/13/12 PEG placed for long-term nutrition
    support 2/2 prolonged swallow dysfunction
  • 3/20/12 Wound upgraded from Stage III to Stage
    IV sacral decubitis ulcer
  • 3/30/12 MBS showed silent aspiration, SLP
    recommends continuation of long-term nutrition
    support

22
New Admission April 10th May 22nd
23
Medical Issues
  • Labs
  • Hyponatremia
  • Hyperphosphatemia
  • Treatments none
  • IVF
  • Day 13 Pt hyponatremic with 250 ml H20 boluses q
    4 hrs
  • low sodium
  • Change boluses to 250 ml H20 q 6 hrs, consider
    diuresis
  • Day 14 1 L NS Bolus
  • Day 20 250 ml NS Bolus NS _at_ 100 ml/hr
  • Day 24 Sodium level within normal limits

24
(No Transcript)
25
?This Admission?
?This Admission?
26
(No Transcript)
27
Day 2 Initial Nutrition Assessment
  • Admission Dx tachycardia of unknown origin
  • Considerations
  • Stage IV Decubitis Ulcer
  • GT feed dependent, on Nepro _at_ 60 ml/hr in rehab
    PTA
  • Needs Assessment
  • 2180-2470 kcal (31-35 kcal/kg)
  • 99-141 g protein (1.4-2 g protein/kg)

Ht 175 cm (59) IBW 72.7 kg (97 of IBW)
Wt 70.5 kg (Weight stable) BMI 22.9 (Normal Weight-for-Height)
28
(No Transcript)
29
Medical Issues Review of Systems
  • Review of Systems
  • GI
  • History of GERD, on prevacid
  • PEG since 2/2012
  • On Nepro _at_ 60 ml/hr at Rehab Facility PTA
  • Respiratory
  • History of Respiratory Failure
  • On Trach Collar
  • Cardiac
  • History of severe Peripheral Vascular Disease
  • On amlodipine, aspirin, heparin, plavix,
    metoprolol, pravachol, terazosin
  • Skin
  • Stage IV Decubitis Ulcer, patient with flexiseal
  • Endocrine
  • On Sliding Scale Insulin, no history of DM

30
Medical Issues Review of Systems
  • Renal
  • On Calcium Acetate/ PhosLo
  • History of renal insufficiency 2/2
    retroperitoneal fibrosis
  • ARF in 1/2012 with CVVH 1/8/12-1/16/12, then
    intermittent dialysis
  • Now off dialysis, Hickman Catheter removed
    3/15/12
  • ID
  • On micafungin, terazosin, ziprasodone
  • Mycamine initiated Day 16, zosyn on Day 20,
  • History of graft infection
  • Psych
  • On ziprasidone for anxiety
  • Additional Meds
  • MCT Oil 15 ml TID
  • Ferrous Sulfate
  • Folic Acid, d/cd Day 13
  • Oxycodone initiated on Day 20, morphine on Day 24

31
Treatment Summary
Day 10
Chest tube placed 2/2 Pleural effusion
?Pleural fluid TG, change TF to Vivonex Add MCT
Oil
Increase Vivonex to Goal Rate
Day 15
D/C MCT Oil
MBS, SLP Recd Mech. Soft Diet
Initiate Mech. Soft, Low Fat Diet, TF to meet gt
90 of needs
Pleural fluid TG gt 110 mg/dl
Day 20
Insufficient Calorie Count Data 0 of needs
Initiate Calorie Count
Day 25
Pigtail clamped
Pigtail removed, TF changed to Nepro
Day 30
32
Goal lt 110 mg/dL
33
Chest Tube Clogged
34
Day 13 Tube Feeding Follow-Up
  • Diet NPO
  • EN Vivonex _at_ 60 ml/hr (Changed from Nepro _at_ 60
    ml/hr) 15 ml MCT Oil TID
  • Recd change to Vivonex _at_ 105 ml/hr
  • 2310 kcal (33 kcal/kg), 1.6 g/kg
  • Medical Progress
  • Day 10 pigtail drain placed
  • Day 11 new diagnosis of chylothorax, CT TG level
    928 mg/dL

9
n/a
n/a
FS 88-123 I/O 2890/1622 foley1620, CT2
131 103 34 100
4.6 20 0.74 100
Labs
35
Day 16 Tube Feeding Follow-Up
  • Diet NPO
  • EN Vivonex _at_ 60 ml/hr 15 ml MCT Oil TID
  • Recd d/c MCT Oil
  • Goal of 105 ml/hr would provide 13 ml/day, close
    to the recommended starting dose of 5 ml TID
  • Medical Progress
  • CT clogged and unclogged
  • Patient receiving 61 of estimated nutrient needs
    from TF 76 of estimated energy needs with MCT
    Oil
  • Signs of tolerance - N/V, Ø GRV, BM (flexiseal)

8.9
1.6
4.2
FS 102-138, 111-118 I/O 2100/1464 void1450,
CT14
133 106 28 101
5.1 17 0.76 101
Labs
36
Day 20 Tube Feeding Follow-Up
  • Medical Progress
  • MBS SLP recommended Mechanical soft, thin
    liquids
  • CT TG Level (Day 17) 361
  • CXR showed L-sided fluid/thickening
  • Diet Mechanical Soft, Low Fat Diet with 11
    assistance
  • EN Vivonex _at_ 95 ml/hr 15 ml MCT Oil TID
  • Recd hold MCT Oil while pt with lt50 po intake
  • Patient receiving 96 of estimated nutrient
    needs, 100 of estimated energy needs with MCT
    Oil po diet
  • Signs of tolerance Ø GRV, BM (flexiseal)

FS 143-159 I/O 3705/2610 Texas2340, CT70,
rectal tube200
9.2
n/a
n/a
135 114 24 86
4.8 14 0.96 86
Labs
37
Day 21 Progress Note
  • Diet Mechanical Soft, Low Fat with 11
    assistance
  • EN Vivonex _at_ 95 ml/hr
  • Medical Progress
  • Calorie Count Initiated Day 21-23

Day 21 Day 22 Day 23
Ø Intake 3 Spoonfuls of Applesauce with Meds Calorie Count discontinued 2/2 insufficient data collection
38
Day 24 Tube Feeding Follow-Up
  • Diet Mechanical soft, Low Fat with 11
    assistance
  • EN Vivonex _at_ 95 ml/hr, MCT Oil d/cd on Day 20
  • Educated nurse to hold for gastric residuals gt
    500 ml, use GI exam
  • Medical Progress
  • 3-Day Calorie Count Average 0
  • Patient with poor appetite related to feelings of
    fullness
  • and lethargy
  • TF held overnight due to high residuals (300 ml)
  • Patient receiving 96 of estimated nutrient
    needs
  • Signs of tolerance GRV, BM

FS 106-130 I/O 1770/2850 Texas2750, CT100
9.7
n/a
n/a
137 117 20 120
4.2 10 1.02 120
Labs
39
Day 27 Tube Feeding Follow-Up
  • Diet Mechanical Soft, Low Fat
  • EN Vivonex _at_ 95 ml/hr
  • Recd change EN back to Nepro _at_ 60 ml/hr, if
    chylothorax resolved
  • Medical Progress
  • Trach change
  • TF held at meal time to increase appetite,
    however patient refusing foods
  • Team plans to remove chest tube in IR today
  • Patient receiving 96 of estimated nutrient
    needs
  • Signs of tolerance Ø GRV, BM (flexiseal)

FS 119-142 (0 units) I/O 2155/1850 CT clamped
11
1.7
3.7
133 113 33 96
4.9 14 0.77 96
Labs
40
Day 30 Tube Feeding Follow-Up
  • Diet Mechanical Soft, Low Fat
  • Recd liberalize diet to mechanical soft
  • EN Nepro _at_ 60 ml/hr
  • Medical Progress
  • Chest tube removed on Day 28
  • Changed TF formula
  • Pseudomonas bacteremia diagnosed
  • Patient receiving 100 of estimated nutrient
    needs
  • Signs of tolerance Ø GRV, BM (flexiseal)

10.6
n/a
n/a
FS 110-140 I/O 2325/1100 Texas1100
134 115 37 109
4.2 14 1.13 109
Labs
41
Possible PES Statements
  • Admission Increased nutrient needs related to
    wound healing evidenced by stage IV sacral
    decubitis ulcer.
  • Day 13 Inadequate enteral nutrition infusion
    related to EN order evidenced by EN meets 61 of
    estimated nutrient needs.
  • Day 27 Less than optimal enteral nutrition
    related to has completed course of specialized TF
    evidenced by clinical condition - chylothorax
    resolved

42
Other Issues
  • Team Plans
  • Tx from Vascular to Med ID
  • Team re-checked pleural fluid TG on Day 20, no
    follow-up value before the CT was removed
  • Nursing Issues
  • Minimal reporting of high residuals, however TF
    were held several times while on Vivonex due to
    feelings of fullness, distention
  • D/C planning
  • Plan to D/C to rehab, until patient with
    pseudomonas UTI and AMS, tx to IMC

43
Literature review
44
Article 1 Review
  • McCray, S., Parrish, C.R. When Chyle Leaks
    Nutrition Management Options. Nutr Issues
    Gastroenterol. 2004 17 60-76
  • McCray, S., Parrish, C.R. Nutritional Management
    of Chyle Leaks An Update. Nutr Issues
    Gastroenterol. 2011 94 12-32
  • Purpose To review the research for nutrition
    interventions for chyle leaks
  • Significance Chylothorax is a rare, but serious
    complication in the clinical setting.
  • References 34 references, 1964-2001 (When Chyle
    Leaks) 35 references, from 1976-2010 (Update)

45
Article 1
  • Subtopics anatomy of chyle leak, diagnosis of
    chyle leak, fat digestion and absorption,
    nutritional management, use of MCT Oil,
    fat-soluble vitamins
  • Goals of MNT
  • 1) Decrease production of chyle fluid in order to
    avoid aggravating the effusion, ascites, or chest
    tube drainage
  • 2) Replace fluid and electrolytes
  • 3) Maintain or replete nutritional status and
    prevent malnutrition
  • Findings
  • Enteral feeding is always preferred
  • There are cases were parenteral nutrition is
    necessary
  • There is a lack of research in this field, and
    more needs to be done with establishing standards
    for enteral and parenteral nutrition in these
    patients

46
  • Relation to the Case
  • CG has a type of chyle leak and was on a low-fat
    enteral formula with MCT oil
  • Limitations
  • Review articles are based on opinion and always
    have a certain amount of bias
  • Questions
  • Why is a semi-elemental formula indicated for
    output lt 500 ml/day?
  • Is there a kcal from fat that makes a formula
    low fat or very low fat?

47
Article 2 Research
  • Allaham, A.H., Estrera, A.L., Miller, C.C.,
    Achouh, P., Safi, H.J. Chylothorax Complicating
    Repairs of the Descending and Thoracoabdominal
    Aorta. Chest, 2006 130 1138-1142.
  • Purpose To analyze the researchers experience
    with chylothorax complicating thoracoabdominal
    aorta repairs and the resulting outcomes
  • Objective To identify pre- and post-operative
    risk factors for chylothorax in this population.
  • Significance Discusses patients with chylothorax
    as a result of complications from descending
    thoracic aortic aneurysm repair (DTAA) and
    thoracic aortic aneurysm repair (DTAA)

48
Article 2
  • References 11 references, from 1986-2003
  • Subjects
  • 5 of 1,159 patients developed chylothorax
    post-operatively
  • Ages 52-72
  • 3 Females, 2 Males
  • 5 out of 5 had DTAA operations
  • 2 were diagnosed lt10 days post-op, 3 were
    diagnosed gt10 days post-op
  • Results
  • Patients undergoing DTAA repair are more likely
    to have their medical course complicated by
    chylothorax (p.006)
  • Patients undergoing reoperations are more likely
    to experience this complication (p.0003)

49
Article 2
  • Conclusions
  • This complication was more likely to occur in
    those who underwent reoperations or multiple
    repairs and those with DTAA
  • Patients were at no greater risk for infectious
    complications
  • This conclusion not generalizable to the entire
    population
  • MNT included NPO with TPN, fluid and electrolyte
    management until daily drainage from chest tube
    was 920 ml/d on average, then initiate
    conservative therapy.
  • Nonoperative management was accomplished in 3 of
    5 patients (60), and 2 patients required left
    thoracotomy with direct ligation.

50
Article 2
  • Limitations
  • Level V
  • Retrospective Chart Review
  • Research collected from 1991-2005
  • Small sample size
  • Some chyle leaks are repaired in the primary
    operation, which is not accounted for in this
    study
  • Relation to the Case
  • CGs chylothorax may be related to his recent AAA
    repair/reoperation
  • CGs chylothorax was resolved using conservative
    management with chest tube drainage and nutrition
    support

51
Article 3 Research
  • Karagianis, J., Sheean, P.M. Managing Secondary
    Chylothorax The Implications for MNT. J Am Diet
    Assoc. 2011 111 600-604.
  • Purpose To illustrate an example of secondary
    chylothorax s/p esophagectomy and highlight the
    approaches to treatment
  • References 25 references, from 1948-2008
  • Significance to Clinical Practice Describes the
    role of the RD in the treatment of chylothorax in
    the transition from high chest tube output and
    TPN, to decreased output on a semi-elemental, MCT
    enteral formula to discharge on a low fat diet.
  • Subtopics Anatomy of a chyle leak, medical and
    surgical management of chylothorax, diet
    modifications, nutrition support, role of RD in
    treatment

52
Article 3
  • Findings
  • The importance of dialogue and discussion with
    the primary service regarding the current
    evidence for conservative vs. aggressive case
    management
  • The necessity of enteral LCT restriction and the
    importance of providing supplementary enteral
    nutrition and perhaps parenteral nutrition
  • The critical nature of MNT for case management
    and for the prevention of nutritional decline
    and the continuity of care from the inpatient to
    the outpatient setting.
  • Limitations
  • Level V research
  • Case Study (n1)
  • Not generalizable

53
Article 3
  • Relation to the Case
  • Adult patient with chylothorax as a surgical
    complication
  • Patient fed enterally when CT output at 340
    ml/day, CG had CT output lt 340 ml/day throughout
    his course and was fed enterally
  • Questions
  • At what chest output is it acceptable to start
    enteral feeds?
  • Or is it more dependent on the color/ consistency
    of the output?
  • What other clinical signs/symptoms indicate
    resolution of the chyle leak/ ability to progress
    to enteral feeds?

54
Conclusions
  • The only research available is retrospective
    chart reviews, and case studies
  • More research needs to be done to establish
    standards for treatment
  • MNT should be based on the RDs clinical judgment
    and specialty
  • We at UMMC see patients every day that are at
    risk for developing chylothorax, and the
    manifestations may be different in different
    populations.
  • Esophageal cancer/ esophagectomy
  • Cirrhosis
  • Aneurysm repair
  • Trauma
  • Congenital heart defects

55
Sources
  1. Allaham, A.H., Estrera, A.L., Miller, C.C.,
    Achouh, P., Safi, H.J. Chylothorax Complicating
    Repairs of the Descending and Thoracoabdominal
    Aorta. Chest, 2006 130 1138-1142.
  2. Karagianis, J., Sheean, P.M. Managing Secondary
    Chylothorax The Implications for MNT. J Am Diet
    Assoc. 2011 111 600-604.
  3. Kilic, D., Sahin, E., Glucan, O., Bolat, B.,
    Turkoz, R., Hatipoglu, A. Octreotide for Treating
    Chylothorax after Cardiac Surgery. Tex Heart I J.
    2005 32 437-439.
  4. Maldonado, F., Hawkins, F.J., Daniels, C.E.,
    Doerr, C.H., Decker, P.A., Ryu, J.R. Pleural
    Fluid Characteristics in Chylothorax. Mayo Clin
    Proc. 2009 84 129-133
  5. McCray, S., Parrish, C.R. Nutritional Management
    of Chyle Leaks An Update. Nutr Issues
    Gastroenterol. 2011 94 12-32
  6. McCray, S., Parrish, C.R. When Chyle Leaks
    Nutrition Management Options. Nutr Issues
    Gastroenterol. 2004 17 60-76.

56
Sources
  • Mikroulis, D., Didilis, V., Bitzikas, G.,
    Bougioukas, G. Octreotide in the Treatment of
    Chylothorax. Chest. 2002 232 2079-2081.
  • Romero, S., Martin, C., Hernandez, L., Verdu, J.,
    Trigo, C., Perez-Mateo, M., Alemany, L.
    Chylothorax in cirrhosis of the liver analysis
    of its frequency and clinical characteristics.
    1998 114 154-159.
  • Selle, J.G., Snyder, W.H., Schreiber, J.T.
    Chylothorax Indications for Surgery. Ann Surg.
    1971 177 245-249.
  • Smoke, A., DeLegge, M.H. Chyle Leaks Consensus
    on Management? Nutr Clin Pract. 2008 23 529
  • Valentine, V.G., Raffin, T.A. The Management of
    Chylothorax. Chest. 1992 102 586-591
View by Category
About This Presentation
Title:

CG: Chylothorax After Abdominal Aortic Aneurysm (AAA) Repair

Description:

Title: PowerPoint Presentation Author: Anna Last modified by: UMMS User Created Date: 3/27/2012 11:08:28 PM Document presentation format: On-screen Show – PowerPoint PPT presentation

Number of Views:84
Avg rating:3.0/5.0
Slides: 56
Provided by: Anna3169
Learn more at: http://annaebondyportfolio.yolasite.com
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: CG: Chylothorax After Abdominal Aortic Aneurysm (AAA) Repair


1
CGChylothorax After Abdominal Aortic Aneurysm
(AAA) Repair
  • By Anna Bondy, Dietetic Intern
  • June 6th, 2012

2
Background Chylothorax5
  • Chyle is a component of lymph that originates
    from the GI tract that contains chylomicrons,
    fat, protein, electrolytes and lymphocytes
  • 1.5-4 L of chyle flows through the thoracic duct
    every day2
  • Lymph also transports Long-chain Triglycerides
    (LCTs) and fat-soluble vitamins
  • A chylothorax is caused by a blockage or
    disruption of the thoracic duct or the
    surrounding lymph system2

3
Background Chylothorax
  • Most dietary fat is in the form of LCTs
  • LCTs are digested by pancreatic enzymes in the
    small bowel, and emulsified by bile salts before
    being absorbed and converted to chylomicrons
  • Chylomicrons enter the lymphatic system through
    lacteals found in the villi
  • 70 of ingested fat will pass through the
    lymphatic system
  • High intake of LCTs increases chyle flow,
    decreased intake of LCTs decreases chyle flow
  • This is the basis for substituting LCTs with
    Medium-chain triglycerides (MCTs) as part of the
    MNT for this condition2

4
(No Transcript)
5
Causes of Chyle Leaks5,6
  • Primary
  • Congenital lymphangiectasia
  • Secondary
  • Lymphoma
  • Penetrating Trauma
  • Lymphoangioleiomyomatosis (LAM)
  • Cirrhosis
  • Tuberculosis
  • Idiopathic
  • Congenital Chylothorax
  • Post operative complications
  • Radical Neck Dissection
  • Cardiothoracic surgery
  • Esophagectomy

6
Causes of Chyle Leaks5,6
  • Pulmonary resection
  • Abdominal aortic aneurysm repair
  • Pancreatic resections
  • According to Allahan, et al, the overall
    incidence of chylothorax in thoracic AAA repair
    patients is 0.41

7
Diagnosis of Chyle Leak
  • Signs Symptoms
  • New pleural effusion, dypsnea1
  • Drainage appears milky or white in about 44 of
    cases (can be clear or reddish-brown)4
  • Biochemical Tests
  • Pleural fluid triglyceride level gt 110 mg/dL
  • Pleural fluid triglyceride level 50 110 mg/dL
    with the presence of chylomicrons in the
    lipoprotein analysis
  • Pleural fluid triglyceride level may be lt 50 if
    patient is fasting, especially after surgery
  • Maldonado, et al 2.7 of patients with
    chylothorax has TG lt 50 due to fasting4

8
Treatment Options
  • Conservative Management
  • Chest tube placement for drainage of chylous
    effusion and use of Medical Nutrition Therapy
  • Pharmacology
  • Octreotide therapy is thought to decrease chyle
    flow, and has been used been successfully in
    neonates with chylothorax
  • Dosing of 50 200 mcg TID5, adjusted for renal
    impairment and liver disease
  • Surgical repair (Thoracic/Lymphatic Duct
    Ligation)
  • Indicated for nutritionally depleted patients,
    especially patients with esophageal disease11
  • Indicated in adults with gt 1500 ml/d of CT output
    x5 days OR children with gt 100 ml age x5 days
  • Indicated if chyle output does not decrease over
    a two week period9

9
From Valentine (1992)
10
Nutrition Implications
  • The medical nutrition therapy for chyle leak
    focuses on restriction of dietary long-chain
    triglycerides while correcting other nutrient
    deficiencies
  • A PO diet low in long-chain triglycerides can be
    very restrictive diet and put patients at risk
    for malnutrition
  • Nutritional deficiencies of calories, fat,
    protein, and fat-soluble vitamins can result from
    the loss of chyle
  • Chyle has 200 calories per liter, 30 g protein
    per liter and contains fat-soluble vitamins
  • A diet without sufficient essential fatty acids
    (EFA) can result in poor wound healing2,5
  • Chyle leaks can lead to immunosuppression, which
    puts patients at higher risk of infection

11
Medical Nutrition Therapy
  • Goals of MNT
  • 1) Decrease production of chyle fluid in order to
    avoid aggravating the effusion, ascites, or chest
    tube drainage
  • 2) Replace fluid and electrolytes
  • 3) Maintain or replete nutritional status and
    prevent malnutrition5
  • Low-fat or fat-free oral diet
  • Fat-free oral supplements, such as Resource
    Breeze or Enlive
  • MCT Oil Supplementation (4-5 Tablespoons of MCT
    oil/day)
  • May cause diarrhea or GI distress
  • Additional Supplementation
  • Essential Fatty Acids (no EFAs in MCT Oil),
    Multivitamin/ Fat-soluble vitamins, Protein
  • Specialized enteral formula
  • Vivonex or other low-fat, high MCT formula
  • Parenteral nutrition (IV lipids do not contribute
    to chyle flow)

12
(No Transcript)
13
Formula Vivonex RTF _at_95 ml/hr Vivonex RTF (250 ml) Peptamen 1.5 (250 ml) Vital 1.5 (250 ml) Vital HN (300 ml) - Powder
Calories 2090 250 375 356 300
Total Fat 24.2 g 2.9 g 14 g 13.5 g 3.3 g
Cal from Fat 10 10 33 33 9.5
MCT 40 9.7 g 146 ml 40 1.2 g 18 ml 70 9.8 g 147 ml 47.5 6.4 g 96 ml 45 1.5 g 23 ml
Price 0.032/ kcal (6000 kcal/191 case) 0.019/ kcal (9000 kcal/170 case) 0.020/ kcal 8532 kcal/172 case) 0.020/ kcal (7200 kcal/146 case)
MCT Oil contains 8.3 calories per gram (1 Tb 15
mL 115 kcal).
14
For chest tube output gt 500 use elemental
formula, for output lt500, semi-elemental formula
may be used.5 Supplement Oral Low-Fat Diet or
Clear Liquid Diet with MCT Oil, Fat Free
Supplements and monitor for nutritional
deficiencies.10
Discharge to Home on a Low-fat Diet with
Outpatient follow-up
15
Meet Patient CG
16
Reasons for Patient Selection
  • Complex Medical History
  • Vascular Disease
  • Stage IV Wounds
  • Renal Insufficiency
  • New Diagnosis of Chylothorax
  • Resolution with appropriate Medical Nutrition
    Therapy

17
General Issues
  • Patient Name CG
  • Age 68 years old
  • Gender Male
  • Admitted 4/10/12 from OSH
  • Intake Triage
  • ? Home TF
  • ? Stage III/IV Pressure Ulcer
  • ? NPO with TF at home

18
General Issues
  • Significant PMH HTN, CAD, severe PVD, HLD, CHF,
    DVT, carotid stenosis, retroperitoneal fibrosis,
    hydronephrosis, infected AAA, TIA, hearing loss,
    ischemic heart disease, L pleural effusion, L
    thoracotomy, hernia, stopped HD 3/2012, HCD, PNA
  • Significant PSH (gt5 years ) aortobifemoral
    artery bypass grafting, endograft repair of a
    proximal pseudoaneurysm, right graft limb
    thrombosis s/p femoral-femoral bypass graft.
    Graft infection s/p right left axillopopliteal
    artery bypass with removal of infected graft in
    LLE RLE.

19
General Issues
  • Significant PSH (2007-2011) Multiple graft
    infections leading to retroperitoneal fibrosis
    and multiple bilateral ureteral stent
    replacements, non-operative aortic aneurysm
  • Social History Wife is major source of support,
    son also participates in decision-making, patient
    mostly nonverbal

20
Recent Admissions
  • Admission 1/3/12-3/1/12
  • 12/24/2011 MRI Thoracic Lumbar Spine
    thrombosed abdominal aortic aneurysm, with
    extension of the aneurysm sac into the L1 and L2
    vertebral bodies.
  • 1/3/2012 Right axillary popliteal graft bypass
    to left axillary popliteal bypass graft with
    excision of infected aortic thoracoabdominal
    aneurysm with left renal artery bypass,
    debridement of anterior lumbar spine
  • 1/3/2012-1/20/2012 SICU Stay complicated by
    respiratory and renal failure
  • 1/21/12 Tracheostomy, 6 Shiley

21
Recent Admissions
  • Admission 3/8/12-4/4/12
  • Worsening sacral decubitis ulcer, open
    thoracoabdominal surgical site
  • Significant Nutritional History
  • 2/13/12 PEG placed for long-term nutrition
    support 2/2 prolonged swallow dysfunction
  • 3/20/12 Wound upgraded from Stage III to Stage
    IV sacral decubitis ulcer
  • 3/30/12 MBS showed silent aspiration, SLP
    recommends continuation of long-term nutrition
    support

22
New Admission April 10th May 22nd
23
Medical Issues
  • Labs
  • Hyponatremia
  • Hyperphosphatemia
  • Treatments none
  • IVF
  • Day 13 Pt hyponatremic with 250 ml H20 boluses q
    4 hrs
  • low sodium
  • Change boluses to 250 ml H20 q 6 hrs, consider
    diuresis
  • Day 14 1 L NS Bolus
  • Day 20 250 ml NS Bolus NS _at_ 100 ml/hr
  • Day 24 Sodium level within normal limits

24
(No Transcript)
25
?This Admission?
?This Admission?
26
(No Transcript)
27
Day 2 Initial Nutrition Assessment
  • Admission Dx tachycardia of unknown origin
  • Considerations
  • Stage IV Decubitis Ulcer
  • GT feed dependent, on Nepro _at_ 60 ml/hr in rehab
    PTA
  • Needs Assessment
  • 2180-2470 kcal (31-35 kcal/kg)
  • 99-141 g protein (1.4-2 g protein/kg)

Ht 175 cm (59) IBW 72.7 kg (97 of IBW)
Wt 70.5 kg (Weight stable) BMI 22.9 (Normal Weight-for-Height)
28
(No Transcript)
29
Medical Issues Review of Systems
  • Review of Systems
  • GI
  • History of GERD, on prevacid
  • PEG since 2/2012
  • On Nepro _at_ 60 ml/hr at Rehab Facility PTA
  • Respiratory
  • History of Respiratory Failure
  • On Trach Collar
  • Cardiac
  • History of severe Peripheral Vascular Disease
  • On amlodipine, aspirin, heparin, plavix,
    metoprolol, pravachol, terazosin
  • Skin
  • Stage IV Decubitis Ulcer, patient with flexiseal
  • Endocrine
  • On Sliding Scale Insulin, no history of DM

30
Medical Issues Review of Systems
  • Renal
  • On Calcium Acetate/ PhosLo
  • History of renal insufficiency 2/2
    retroperitoneal fibrosis
  • ARF in 1/2012 with CVVH 1/8/12-1/16/12, then
    intermittent dialysis
  • Now off dialysis, Hickman Catheter removed
    3/15/12
  • ID
  • On micafungin, terazosin, ziprasodone
  • Mycamine initiated Day 16, zosyn on Day 20,
  • History of graft infection
  • Psych
  • On ziprasidone for anxiety
  • Additional Meds
  • MCT Oil 15 ml TID
  • Ferrous Sulfate
  • Folic Acid, d/cd Day 13
  • Oxycodone initiated on Day 20, morphine on Day 24

31
Treatment Summary
Day 10
Chest tube placed 2/2 Pleural effusion
?Pleural fluid TG, change TF to Vivonex Add MCT
Oil
Increase Vivonex to Goal Rate
Day 15
D/C MCT Oil
MBS, SLP Recd Mech. Soft Diet
Initiate Mech. Soft, Low Fat Diet, TF to meet gt
90 of needs
Pleural fluid TG gt 110 mg/dl
Day 20
Insufficient Calorie Count Data 0 of needs
Initiate Calorie Count
Day 25
Pigtail clamped
Pigtail removed, TF changed to Nepro
Day 30
32
Goal lt 110 mg/dL
33
Chest Tube Clogged
34
Day 13 Tube Feeding Follow-Up
  • Diet NPO
  • EN Vivonex _at_ 60 ml/hr (Changed from Nepro _at_ 60
    ml/hr) 15 ml MCT Oil TID
  • Recd change to Vivonex _at_ 105 ml/hr
  • 2310 kcal (33 kcal/kg), 1.6 g/kg
  • Medical Progress
  • Day 10 pigtail drain placed
  • Day 11 new diagnosis of chylothorax, CT TG level
    928 mg/dL

9
n/a
n/a
FS 88-123 I/O 2890/1622 foley1620, CT2
131 103 34 100
4.6 20 0.74 100
Labs
35
Day 16 Tube Feeding Follow-Up
  • Diet NPO
  • EN Vivonex _at_ 60 ml/hr 15 ml MCT Oil TID
  • Recd d/c MCT Oil
  • Goal of 105 ml/hr would provide 13 ml/day, close
    to the recommended starting dose of 5 ml TID
  • Medical Progress
  • CT clogged and unclogged
  • Patient receiving 61 of estimated nutrient needs
    from TF 76 of estimated energy needs with MCT
    Oil
  • Signs of tolerance - N/V, Ø GRV, BM (flexiseal)

8.9
1.6
4.2
FS 102-138, 111-118 I/O 2100/1464 void1450,
CT14
133 106 28 101
5.1 17 0.76 101
Labs
36
Day 20 Tube Feeding Follow-Up
  • Medical Progress
  • MBS SLP recommended Mechanical soft, thin
    liquids
  • CT TG Level (Day 17) 361
  • CXR showed L-sided fluid/thickening
  • Diet Mechanical Soft, Low Fat Diet with 11
    assistance
  • EN Vivonex _at_ 95 ml/hr 15 ml MCT Oil TID
  • Recd hold MCT Oil while pt with lt50 po intake
  • Patient receiving 96 of estimated nutrient
    needs, 100 of estimated energy needs with MCT
    Oil po diet
  • Signs of tolerance Ø GRV, BM (flexiseal)

FS 143-159 I/O 3705/2610 Texas2340, CT70,
rectal tube200
9.2
n/a
n/a
135 114 24 86
4.8 14 0.96 86
Labs
37
Day 21 Progress Note
  • Diet Mechanical Soft, Low Fat with 11
    assistance
  • EN Vivonex _at_ 95 ml/hr
  • Medical Progress
  • Calorie Count Initiated Day 21-23

Day 21 Day 22 Day 23
Ø Intake 3 Spoonfuls of Applesauce with Meds Calorie Count discontinued 2/2 insufficient data collection
38
Day 24 Tube Feeding Follow-Up
  • Diet Mechanical soft, Low Fat with 11
    assistance
  • EN Vivonex _at_ 95 ml/hr, MCT Oil d/cd on Day 20
  • Educated nurse to hold for gastric residuals gt
    500 ml, use GI exam
  • Medical Progress
  • 3-Day Calorie Count Average 0
  • Patient with poor appetite related to feelings of
    fullness
  • and lethargy
  • TF held overnight due to high residuals (300 ml)
  • Patient receiving 96 of estimated nutrient
    needs
  • Signs of tolerance GRV, BM

FS 106-130 I/O 1770/2850 Texas2750, CT100
9.7
n/a
n/a
137 117 20 120
4.2 10 1.02 120
Labs
39
Day 27 Tube Feeding Follow-Up
  • Diet Mechanical Soft, Low Fat
  • EN Vivonex _at_ 95 ml/hr
  • Recd change EN back to Nepro _at_ 60 ml/hr, if
    chylothorax resolved
  • Medical Progress
  • Trach change
  • TF held at meal time to increase appetite,
    however patient refusing foods
  • Team plans to remove chest tube in IR today
  • Patient receiving 96 of estimated nutrient
    needs
  • Signs of tolerance Ø GRV, BM (flexiseal)

FS 119-142 (0 units) I/O 2155/1850 CT clamped
11
1.7
3.7
133 113 33 96
4.9 14 0.77 96
Labs
40
Day 30 Tube Feeding Follow-Up
  • Diet Mechanical Soft, Low Fat
  • Recd liberalize diet to mechanical soft
  • EN Nepro _at_ 60 ml/hr
  • Medical Progress
  • Chest tube removed on Day 28
  • Changed TF formula
  • Pseudomonas bacteremia diagnosed
  • Patient receiving 100 of estimated nutrient
    needs
  • Signs of tolerance Ø GRV, BM (flexiseal)

10.6
n/a
n/a
FS 110-140 I/O 2325/1100 Texas1100
134 115 37 109
4.2 14 1.13 109
Labs
41
Possible PES Statements
  • Admission Increased nutrient needs related to
    wound healing evidenced by stage IV sacral
    decubitis ulcer.
  • Day 13 Inadequate enteral nutrition infusion
    related to EN order evidenced by EN meets 61 of
    estimated nutrient needs.
  • Day 27 Less than optimal enteral nutrition
    related to has completed course of specialized TF
    evidenced by clinical condition - chylothorax
    resolved

42
Other Issues
  • Team Plans
  • Tx from Vascular to Med ID
  • Team re-checked pleural fluid TG on Day 20, no
    follow-up value before the CT was removed
  • Nursing Issues
  • Minimal reporting of high residuals, however TF
    were held several times while on Vivonex due to
    feelings of fullness, distention
  • D/C planning
  • Plan to D/C to rehab, until patient with
    pseudomonas UTI and AMS, tx to IMC

43
Literature review
44
Article 1 Review
  • McCray, S., Parrish, C.R. When Chyle Leaks
    Nutrition Management Options. Nutr Issues
    Gastroenterol. 2004 17 60-76
  • McCray, S., Parrish, C.R. Nutritional Management
    of Chyle Leaks An Update. Nutr Issues
    Gastroenterol. 2011 94 12-32
  • Purpose To review the research for nutrition
    interventions for chyle leaks
  • Significance Chylothorax is a rare, but serious
    complication in the clinical setting.
  • References 34 references, 1964-2001 (When Chyle
    Leaks) 35 references, from 1976-2010 (Update)

45
Article 1
  • Subtopics anatomy of chyle leak, diagnosis of
    chyle leak, fat digestion and absorption,
    nutritional management, use of MCT Oil,
    fat-soluble vitamins
  • Goals of MNT
  • 1) Decrease production of chyle fluid in order to
    avoid aggravating the effusion, ascites, or chest
    tube drainage
  • 2) Replace fluid and electrolytes
  • 3) Maintain or replete nutritional status and
    prevent malnutrition
  • Findings
  • Enteral feeding is always preferred
  • There are cases were parenteral nutrition is
    necessary
  • There is a lack of research in this field, and
    more needs to be done with establishing standards
    for enteral and parenteral nutrition in these
    patients

46
  • Relation to the Case
  • CG has a type of chyle leak and was on a low-fat
    enteral formula with MCT oil
  • Limitations
  • Review articles are based on opinion and always
    have a certain amount of bias
  • Questions
  • Why is a semi-elemental formula indicated for
    output lt 500 ml/day?
  • Is there a kcal from fat that makes a formula
    low fat or very low fat?

47
Article 2 Research
  • Allaham, A.H., Estrera, A.L., Miller, C.C.,
    Achouh, P., Safi, H.J. Chylothorax Complicating
    Repairs of the Descending and Thoracoabdominal
    Aorta. Chest, 2006 130 1138-1142.
  • Purpose To analyze the researchers experience
    with chylothorax complicating thoracoabdominal
    aorta repairs and the resulting outcomes
  • Objective To identify pre- and post-operative
    risk factors for chylothorax in this population.
  • Significance Discusses patients with chylothorax
    as a result of complications from descending
    thoracic aortic aneurysm repair (DTAA) and
    thoracic aortic aneurysm repair (DTAA)

48
Article 2
  • References 11 references, from 1986-2003
  • Subjects
  • 5 of 1,159 patients developed chylothorax
    post-operatively
  • Ages 52-72
  • 3 Females, 2 Males
  • 5 out of 5 had DTAA operations
  • 2 were diagnosed lt10 days post-op, 3 were
    diagnosed gt10 days post-op
  • Results
  • Patients undergoing DTAA repair are more likely
    to have their medical course complicated by
    chylothorax (p.006)
  • Patients undergoing reoperations are more likely
    to experience this complication (p.0003)

49
Article 2
  • Conclusions
  • This complication was more likely to occur in
    those who underwent reoperations or multiple
    repairs and those with DTAA
  • Patients were at no greater risk for infectious
    complications
  • This conclusion not generalizable to the entire
    population
  • MNT included NPO with TPN, fluid and electrolyte
    management until daily drainage from chest tube
    was 920 ml/d on average, then initiate
    conservative therapy.
  • Nonoperative management was accomplished in 3 of
    5 patients (60), and 2 patients required left
    thoracotomy with direct ligation.

50
Article 2
  • Limitations
  • Level V
  • Retrospective Chart Review
  • Research collected from 1991-2005
  • Small sample size
  • Some chyle leaks are repaired in the primary
    operation, which is not accounted for in this
    study
  • Relation to the Case
  • CGs chylothorax may be related to his recent AAA
    repair/reoperation
  • CGs chylothorax was resolved using conservative
    management with chest tube drainage and nutrition
    support

51
Article 3 Research
  • Karagianis, J., Sheean, P.M. Managing Secondary
    Chylothorax The Implications for MNT. J Am Diet
    Assoc. 2011 111 600-604.
  • Purpose To illustrate an example of secondary
    chylothorax s/p esophagectomy and highlight the
    approaches to treatment
  • References 25 references, from 1948-2008
  • Significance to Clinical Practice Describes the
    role of the RD in the treatment of chylothorax in
    the transition from high chest tube output and
    TPN, to decreased output on a semi-elemental, MCT
    enteral formula to discharge on a low fat diet.
  • Subtopics Anatomy of a chyle leak, medical and
    surgical management of chylothorax, diet
    modifications, nutrition support, role of RD in
    treatment

52
Article 3
  • Findings
  • The importance of dialogue and discussion with
    the primary service regarding the current
    evidence for conservative vs. aggressive case
    management
  • The necessity of enteral LCT restriction and the
    importance of providing supplementary enteral
    nutrition and perhaps parenteral nutrition
  • The critical nature of MNT for case management
    and for the prevention of nutritional decline
    and the continuity of care from the inpatient to
    the outpatient setting.
  • Limitations
  • Level V research
  • Case Study (n1)
  • Not generalizable

53
Article 3
  • Relation to the Case
  • Adult patient with chylothorax as a surgical
    complication
  • Patient fed enterally when CT output at 340
    ml/day, CG had CT output lt 340 ml/day throughout
    his course and was fed enterally
  • Questions
  • At what chest output is it acceptable to start
    enteral feeds?
  • Or is it more dependent on the color/ consistency
    of the output?
  • What other clinical signs/symptoms indicate
    resolution of the chyle leak/ ability to progress
    to enteral feeds?

54
Conclusions
  • The only research available is retrospective
    chart reviews, and case studies
  • More research needs to be done to establish
    standards for treatment
  • MNT should be based on the RDs clinical judgment
    and specialty
  • We at UMMC see patients every day that are at
    risk for developing chylothorax, and the
    manifestations may be different in different
    populations.
  • Esophageal cancer/ esophagectomy
  • Cirrhosis
  • Aneurysm repair
  • Trauma
  • Congenital heart defects

55
Sources
  1. Allaham, A.H., Estrera, A.L., Miller, C.C.,
    Achouh, P., Safi, H.J. Chylothorax Complicating
    Repairs of the Descending and Thoracoabdominal
    Aorta. Chest, 2006 130 1138-1142.
  2. Karagianis, J., Sheean, P.M. Managing Secondary
    Chylothorax The Implications for MNT. J Am Diet
    Assoc. 2011 111 600-604.
  3. Kilic, D., Sahin, E., Glucan, O., Bolat, B.,
    Turkoz, R., Hatipoglu, A. Octreotide for Treating
    Chylothorax after Cardiac Surgery. Tex Heart I J.
    2005 32 437-439.
  4. Maldonado, F., Hawkins, F.J., Daniels, C.E.,
    Doerr, C.H., Decker, P.A., Ryu, J.R. Pleural
    Fluid Characteristics in Chylothorax. Mayo Clin
    Proc. 2009 84 129-133
  5. McCray, S., Parrish, C.R. Nutritional Management
    of Chyle Leaks An Update. Nutr Issues
    Gastroenterol. 2011 94 12-32
  6. McCray, S., Parrish, C.R. When Chyle Leaks
    Nutrition Management Options. Nutr Issues
    Gastroenterol. 2004 17 60-76.

56
Sources
  • Mikroulis, D., Didilis, V., Bitzikas, G.,
    Bougioukas, G. Octreotide in the Treatment of
    Chylothorax. Chest. 2002 232 2079-2081.
  • Romero, S., Martin, C., Hernandez, L., Verdu, J.,
    Trigo, C., Perez-Mateo, M., Alemany, L.
    Chylothorax in cirrhosis of the liver analysis
    of its frequency and clinical characteristics.
    1998 114 154-159.
  • Selle, J.G., Snyder, W.H., Schreiber, J.T.
    Chylothorax Indications for Surgery. Ann Surg.
    1971 177 245-249.
  • Smoke, A., DeLegge, M.H. Chyle Leaks Consensus
    on Management? Nutr Clin Pract. 2008 23 529
  • Valentine, V.G., Raffin, T.A. The Management of
    Chylothorax. Chest. 1992 102 586-591
About PowerShow.com