CG: Chylothorax After Abdominal Aortic Aneurysm (AAA) Repair

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CGChylothorax After Abdominal Aortic Aneurysm
(AAA) Repair

• By Anna Bondy, Dietetic Intern
• June 6th, 2012

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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

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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

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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

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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

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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

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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

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From Valentine (1992)
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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

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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)

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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).
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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
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Meet Patient CG
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Reasons for Patient Selection

• Complex Medical History
• Vascular Disease
• Stage IV Wounds
• Renal Insufficiency
• New Diagnosis of Chylothorax
• Resolution with appropriate Medical Nutrition
  Therapy

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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

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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.

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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

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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

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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

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New Admission April 10th May 22nd
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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

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?This Admission?
?This Admission?
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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)
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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

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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

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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
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Goal lt 110 mg/dL
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Chest Tube Clogged
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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

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n/a
n/a
FS 88-123 I/O 2890/1622 foley1620, CT2
131 103 34 100
4.6 20 0.74 100
Labs
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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
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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
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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
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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
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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
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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
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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

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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

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Literature review
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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)

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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

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• 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?

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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)

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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)

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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.

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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

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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

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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

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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?

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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

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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
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• 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
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  1998 114 154-159.
• Selle, J.G., Snyder, W.H., Schreiber, J.T.
  Chylothorax Indications for Surgery. Ann Surg.
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• Smoke, A., DeLegge, M.H. Chyle Leaks Consensus
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• Valentine, V.G., Raffin, T.A. The Management of
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