CG:
Chylothorax After
Abdominal Aortic
Aneurysm (AAA)
Repair
By Anna Bondy, Dietetic Intern
June 6th, 2012
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
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
Causes of Chyle Leaks5,6
Primary:
• Congenital
lymphangiectasia
Secondary:
• Lymphoma
• Penetrating Trauma
• Lymphoangioleiomyo
matosis (LAM)
• Cirrhosis
• Tuberculosis
• Idiopathic
• Congenital
Chylothorax
• Post operative
complications
• Radical Neck
Dissection
• Cardiothoracic
surgery
• Esophagectomy
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 0.4%1
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 > 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 < 50 if patient is fasting,
especially after surgery
• Maldonado, et al: 2.7% of patients with chylothorax has TG < 50 due
to fasting4
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 > 1500 ml/d of CT output x5 days OR
children with > 100 ml * age x5 days
• Indicated if chyle output does not decrease over a two week
period9
From:
Valentine
(1992)
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
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)
Formula
Vivonex RTF Vivonex
@95 ml/hr 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
$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)
Price
MCT Oil contains 8.3 calories per
gram (1 Tb = 15 mL = 115 kcal).
Chest Tube Output with TG > 100 mg/dL or 50110 with high concentration of chylomicrons
Existing
Malnutrition?
Yes: NPO with
TPN
High Chest Tube
Output?
Consider Adding
Octreotide3,7
After 5-day trial, Is
output decreasing and
<1500 ml/day?9
Yes: Begin feeding
No: Consider surgical
repair after 1-2 weeks11
or if malnutrition
develops2
For chest tube output > 500 use elemental
formula, for output <500, 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
No: Low-fat/Fat-free Oral Diet
OR TF with high percentage of
fat from MCT Oil
Is chyle flow decreasing?
No7
Yes: Continue Current Nutrition
Plan
Discharge to Home on a Lowfat Diet with Outpatient followup
Meet Patient CG
Reasons for Patient Selection
• Complex Medical History
• Vascular Disease
• Stage IV Wounds
• Renal Insufficiency
• New Diagnosis of Chylothorax
• Resolution with appropriate Medical Nutrition Therapy
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
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 (>5 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.
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
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
New Admission:
th
nd
April 10 – May 22
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 @ 100 ml/hr
• Day 24: Sodium level within normal limits
This Admission
This Admission
Day 2: Initial Nutrition
Assessment
• Admission Dx: tachycardia of unknown origin
• Considerations
• Stage IV Decubitis Ulcer
• GT feed dependent, on Nepro @ 60 ml/hr in rehab PTA
Ht: 175 cm
(5’9”)
IBW: 72.7 kg
(97% of IBW)
Wt: 70.5 kg
(Weight stable)
BMI: 22.9
(Normal Weight-for-Height)
• Needs Assessment:
• 2180-2470 kcal (31-35 kcal/kg)
• 99-141 g protein (1.4-2 g protein/kg)
Medical Issues: Review of Systems
• Review of Systems
• GI:
• History of GERD, on prevacid
• PEG since 2/2012
• On Nepro @ 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
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/c’d Day 13
Oxycodone initiated on Day 20, morphine on Day 24
Treatment Summary
Chest tube placed
2/2 Pleural effusion
Day 10
Pleural fluid TG,
change TF to
Vivonex & Add MCT
Oil
Day 15
D/C MCT Oil
Increase Vivonex to
Goal Rate
MBS, SLP Rec’d
Mech. Soft Diet
Pleural fluid TG > 110
mg/dl
Insufficient Calorie
Count Data ~ 0% of
needs
Pigtail removed, TF
changed to Nepro
Day 20
Day 25
Initiate Mech. Soft,
Low Fat Diet, TF to
meet > 90% of
needs
Initiate Calorie
Count
Pigtail clamped
Day 30
Goal < 110 mg/dL
Chest
Tube
Clogged
Day 13: Tube Feeding Follow-Up
• Diet: NPO
• EN: Vivonex @ 60 ml/hr (Changed from Nepro @ 60 ml/hr) +
15 ml MCT Oil TID
• Rec’d change to Vivonex @ 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
Labs
131
103
34
4.6
20
0.74
100
FS: 88-123
n/a
n/a
I/O= 2890/1622;
foley=1620, CT=2
Day 16: Tube Feeding Follow-Up
• Diet: NPO
• EN: Vivonex @ 60 ml/hr + 15 ml MCT Oil TID
• Rec’d 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, ∅ GRV, +BM (flexiseal)
8.9
Labs
133
106
28
5.1
17
0.76
101
1.6
4.2
FS: 102-138, 111-118
I/O =2100/1464; void=1450, CT=14
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 1:1 assistance
• EN: Vivonex @ 95 ml/hr + 15 ml MCT Oil TID
• Rec’d hold MCT Oil while pt with <50% po intake
• Patient receiving 96% of estimated nutrient needs, 100% of
estimated energy needs with MCT Oil + po diet
• Signs of tolerance: ∅ GRV, +BM (flexiseal)
Labs
135
114
24
4.8
14
0.96
9.2
86
n/a
n/a
FS: 143-159
I/O =3705/2610; Texas=2340,
CT=70, rectal tube=200
Day 21: Progress Note
• Diet: Mechanical Soft, Low Fat with 1:1 assistance
• EN: Vivonex @ 95 ml/hr
• Medical Progress:
• Calorie Count Initiated Day 21-23
Day 21
Day 22
Day 23
∅ Intake
3 Spoonfuls of
Applesauce with
Meds
Calorie Count
discontinued 2/2
insufficient data
collection
Day 24: Tube Feeding Follow-Up
• Diet: Mechanical soft, Low Fat with 1:1 assistance
• EN: Vivonex @ 95 ml/hr, MCT Oil d/c’d on Day 20
• Educated nurse to hold for gastric residuals > 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
Labs
137
117
20
4.2
10
1.02
9.7
120
n/a
n/a
FS: 106-130
I/O = 1770/2850; Texas=2750,
CT=100
Day 27: Tube Feeding Follow-Up
• Diet: Mechanical Soft, Low Fat
• EN: Vivonex @ 95 ml/hr
• Rec’d change EN back to Nepro @ 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: ∅ GRV, +BM (flexiseal)
Labs
133
113
33
4.9
14
0.77
11
96
1.7
3.7
FS: 119-142 (0 units)
I/O = 2155/1850; CT clamped
Day 30: Tube Feeding Follow-Up
• Diet: Mechanical Soft, Low Fat
• Rec’d liberalize diet to mechanical soft
• EN: Nepro @ 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: ∅ GRV, +BM (flexiseal)
Labs
134
115
37
4.2
14
1.13
10.6
109
FS: 110-140
n/a
n/a
I/O =2325/1100; Texas=1100
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
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
Literature review
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: 1232
• 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)
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
• 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 < 500
ml/day?
• Is there a %kcal from fat that makes a formula “low fat” or “very
low fat”?
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: 11381142.
• 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)
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 <10 days post-op, 3 were diagnosed >10 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)
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.
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:
• CG’s chylothorax may be related to his recent AAA
repair/reoperation
• CG’s chylothorax was resolved using conservative management
with chest tube drainage and nutrition support
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 semielemental, 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
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 (n=1)
• Not generalizable
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 < 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?
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 RD’s 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
Sources
1.
2.
3.
4.
5.
6.
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.
Karagianis, J., Sheean, P.M. Managing Secondary Chylothorax: The
Implications for MNT. J Am Diet Assoc. 2011; 111: 600-604.
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.
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
McCray, S., Parrish, C.R. Nutritional Management of Chyle Leaks: An
Update. Nutr Issues Gastroenterol. 2011; 94: 12-32
McCray, S., Parrish, C.R. When Chyle Leaks: Nutrition Management
Options. Nutr Issues Gastroenterol. 2004; 17: 60-76.
Sources
7. Mikroulis, D., Didilis, V., Bitzikas, G., Bougioukas, G. Octreotide in the
Treatment of Chylothorax. Chest. 2002; 232: 2079-2081.
8. 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.
9. Selle, J.G., Snyder, W.H., Schreiber, J.T. Chylothorax: Indications for Surgery.
Ann Surg. 1971; 177: 245-249.
10. Smoke, A., DeLegge, M.H. Chyle Leaks: Consensus on Management? Nutr
Clin Pract. 2008; 23: 529
11. Valentine, V.G., Raffin, T.A. The Management of Chylothorax. Chest. 1992;
102: 586-591