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CG: Chylothorax After Abdominal Aortic Aneurysm (AAA) Repair

CG: Chylothorax After Abdominal Aortic Aneurysm (AAA) Repair. By Anna Bondy, Dietetic Intern June 6 th, 2012. Background: Chylothorax 5. Chyle is a component of lymph that originates from the GI tract that contains chylomicrons, fat, protein, electrolytes and lymphocytes

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CG: Chylothorax After Abdominal Aortic Aneurysm (AAA) Repair

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  1. CG:Chylothorax 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. 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

  5. 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

  6. 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

  7. 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

  8. From: Valentine (1992)

  9. 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

  10. 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)

  11. MCT Oil contains 8.3 calories per gram (1 Tb = 15 mL = 115 kcal).

  12. 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 Discharge to Home on a Low-fat Diet with Outpatient follow-up

  13. Meet Patient CG

  14. Reasons for Patient Selection • Complex Medical History • Vascular Disease • Stage IV Wounds • Renal Insufficiency • New Diagnosis of Chylothorax • Resolution with appropriate Medical Nutrition Therapy

  15. General Issues • Patient Name: CG • Age: 68 years old • Gender: Male • Admitted: 4/10/12 from OSH • Intake Triage:  Home TF  Stage III/IVPressure Ulcer  NPO with TF at home

  16. 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.

  17. 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

  18. 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

  19. New Admission: April 10th – May 22nd

  20. 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

  21. This Admission This Admission

  22. 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 • Needs Assessment: • 2180-2470 kcal (31-35 kcal/kg) • 99-141 g protein (1.4-2 g protein/kg)

  23. 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

  24. 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

  25. Treatment Summary Chest tube placed 2/2 Pleural effusion Day 10 Pleural fluid TG, change TF to Vivonex & Add MCT Oil Increase Vivonex to Goal Rate Day 15 D/C MCT Oil MBS, SLP Rec’d Mech. Soft Diet Initiate Mech. Soft, Low Fat Diet, TF to meet > 90% of needs Pleural fluid TG > 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

  26. Goal < 110 mg/dL

  27. Chest Tube Clogged

  28. 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 FS: 88-123 I/O= 2890/1622; foley=1620, CT=2 Labs

  29. 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) FS: 102-138, 111-118 I/O =2100/1464; void=1450, CT=14 Labs

  30. 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) FS: 143-159 I/O =3705/2610; Texas=2340, CT=70, rectal tube=200 Labs

  31. 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

  32. 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 FS: 106-130 I/O = 1770/2850; Texas=2750, CT=100 Labs

  33. 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) FS: 119-142 (0 units) I/O = 2155/1850; CT clamped Labs

  34. 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) FS: 110-140 I/O =2325/1100; Texas=1100 Labs

  35. 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

  36. 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

  37. Literature review

  38. 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)

  39. 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

  40. 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”?

  41. 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: Toanalyze 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)

  42. 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)

  43. 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.

  44. 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

  45. 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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