Pediatric Nurse Practitioner Boston Children's Hospital Newton, Massachusetts, United States
Abstract: INTRODUCTION/OBJECTIVE Chylothorax is a known risk associated with an increase in morbidity and mortality in pediatric patients following congenital heart surgery. Causes may include high venous pressures, injury to the lymphatic system or thrombus formation. Although the incidence of chylothorax is relatively low, the impact on clinical outcomes may be significant. Chylothorax has been associated with extended ventilation time, prolonged periods of NPO or limited nutrition, longer length of stay and higher risk of mortality. Our objective was to develop an algorithm to standardize the identification and management of chylothorax.
METHODS Patients admitted to the Pediatric Cardiac Intensive Care Unit (CICU) over a 6-month period, who developed a chylothorax after cardiac surgery, were managed by the algorithm. Patient and clinical characteristics, diagnostic testing and management data were collected and described. Results were then compared to a patient cohort (n=14) prior to the implementation of the algorithm to evaluate for feasibility, adherence, and effectiveness.
RESULTS Over a 6-month period, post development and implementation of algorithm, 16/460 patients were diagnosed with chylothorax (incidence 3.5%). Demographic patient characteristics were similar in the pre (n=14) and post cohorts (n=16). Single ventricle and arch anomaly surgeries accounted for greater than 50% of chylothorax diagnoses and 19% of patients had an associated congenital syndrome. In the post algorithm cohort, identification of chylothorax was 2 days earlier (pre, 9 days vs post, 7 days), adherence to the algorithm were increased with laboratory tests for triglycerides and lymphocytes drawn (pre, 64%, post, 88%) and neck vessel ultrasound (pre, 36%, post, 100%). Of note thrombus was found in 37.5% of the post cohort. The median days for resolution of chylothorax was 12 days.
Conclusion The utilization of a standardized algorithm was feasible. Adherence of the algorithm supported earlier identification, diagnostic testing, and management. Further evaluation will be conducted with a larger cohort to examine effectiveness.
