Pediatric Critical Care Fellow Medical College of Wisconsin Wauwatosa, Wisconsin, United States
Abstract:
Introduction: Chylothorax (CTX) after pediatric cardiac surgery is common, and often conservative management with dietary changes will lead to resolution of CTX within 10 days of diagnosis. Chylothorax persisting beyond this point is considered “refractory,” and may be associated with higher rates of morbidity and mortality. It may also be associated with a variety of treatment options. With no existing consensus guidelines for management of refractory CTX and significant institutional variability, a survey was developed to address this knowledge gap.
Methods: Within the Pediatric Cardiac Critical Care Consortium (PC4) Chylothorax Work Group, a survey was created focusing on therapies known to be used in the management of refractory CTX and timing of use. The survey was sent electronically to one representative from each center in the workgroup (n=22), who was to discuss the survey with their multi-disciplinary practice group and achieve consensus on responses. Survey results were summarized and reported as percentage frequency of given responses.
Results: Seventeen of 22 centers submitted complete responses. Of these 17 centers, 10 perform 350 or more congenital heart surgeries per year, 3 perform 250-349, and 4 perform < 250. Six centers have an established lymphatic disorders team, and 3 have a treatment protocol for refractory CTX. While 10 centers report allowing fat-modified feeds after a period of nil-per-os (NPO), the remainder continue NPO status until CTX is resolved. Prophylactic anticoagulation is used by 11/17 centers for the following indications: high chest tube output (5/17), history of thrombus (8/17), specific cardiac lesion (8/17), and all patients (1/17). Octreotide is used by 13/17 centers with variable timing. Sildenafil is used in 8 centers, and 6 centers report using steroids for the treatment of chylothorax. Propranolol, midodrine, MEK inhibitors and sirolimus are used rarely. Nine centers utilize pleurodesis, all >20 days after diagnosis, with 6 using doxycycline and 3 using mechanical means. Two centers report utilizing a blood patch. Surgical thoracic duct ligation is performed in 15/17 institutions (>20 days after CTX diagnosis at 13/17 and 10-20 days after diagnosis at 2/17). Diagnostic lymphatic imaging is obtained in only 7/15 centers that perform thoracic duct ligation. Use of other secondary invasive interventions is displayed in Figure 1.
Conclusions: A survey of congenital heart centers confirm significant variability in management strategies. Knowledge of current practices and available treatment options may allow for creation of a standardized treatment algorithm which could lead to identification of superior therapies and improve care.
