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Chylothorax

Chylothorax. Dawn Reed. Little Miss KH. Female Birth/Admit date: Oct. 14, 2013 Birth weight: 3.6 kg (7 lbs , 14 oz ) Length: 51 cm (20 in) Pre-diagnosed with aortic coarctation Parents were able to prepare for hospital stay and plan on delivering at U of U Hospital.

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Chylothorax

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  1. Chylothorax Dawn Reed

  2. Little Miss KH • Female • Birth/Admit date: Oct. 14, 2013 • Birth weight: 3.6 kg (7 lbs, 14 oz) • Length: 51 cm (20 in) • Pre-diagnosed with aortic coarctation • Parents were able to prepare for hospital stay and plan on delivering at U of U Hospital • Family Social History: • Parents were married • 3 siblings • LDS • Wendover, UT

  3. Time Spent at Primary Children’s Hospital • Cardiac Defects: • Aortic coarctation • VSD, ASD • AV block and pacemaker • Chylothorax • IV infiltrate

  4. Cardiac Defects Coarctation ASD

  5. Operation Timetable

  6. Lymphatic System • Functions: • Fluid balance: Removal of interstitial fluid from tissues • Fat absorption: Absorbs fats from the intestine and transports into the blood flow • Immunity and defense: Filters microorganisms and foreign substances, transports WBCs

  7. Chylothorax • Pleural effusions • Presence of lymphatic fluid in the pleural space • Cause: leak in the thoracic duct • OR lymphatic abnormalities • Trauma or damage to the thoracic duct • Chyle: • Composed of chylomicrons & lymph • Purpose: absorption and transport of LCT in the intestines • Responsible for absorption of fat-soluble vitamins • High losses are of great nutritional concern

  8. Diagnosis Diagnosis Chest X-ray  confirms presence of pleural fluid Analyze the fluid Elevated lymphocytes Elevated triglycerides High total protein content Signs and Symptoms • Cough • Dyspnea • Chest discomfort • Pain with breathing • Dependent upon size of chylothorax Normal Pleural Effusion

  9. Management and Treatment Nutrition Management Very low-fat diet Majority of fats from MCTs Gut rest Parenteral nutrition Trial feeds (low-fat or MCT enriched)  decreased output? Feeds: Skimmed breast milk enriched with MCT, protein, source of EFA Specialty formulas Medical Management • Includes the use of: • Somatostatins • Octreotide • Reduces intestinal secretions and inhibits lymph excretion • Pleural drainage (chest tubes) • Watch for decreased output

  10. Monitoring and Resolution • Monitor: • Albumin • Electrolytes • Fat-soluble vitamins • Usually resolves without extensive treatment

  11. Other Events While at Hospital • Chylous drainage from chest tubes (3) was variable. • Chest tubes removed on 11/1 • Respiratory support • 10/22 – Development of small ileus  Stop and restart feeds • 10/22 – IV infiltrate with arginine chloride on left hand • KH was followed by multiple disciplines throughout her stay: • Wound care, Plastics for IV infiltrate • ST – worked on normal oral cues • PT • OT

  12. Nutrition Care Process: Anthros • Weight 75%ile • Length 75%ile • Appropriate weight gain Weight: Length: 51 cm

  13. Biochemical • Hematocrit consistently low • WBC variable, occasional high • WNL: • Triglycerides • Albumin • RFP • Creatinine • Electrolytes

  14. Medications • Acetaminophen • Bacitracin • Omeprazole • Oxycodone • Milrinone • Octreotide • Dopamine • Prevacid • Lasix • PGEs

  15. Estimated Needs *Based on ABW

  16. Diagnoses • Increased nutrient needs r/t physiological causes increasing nutrient needs d/t disease/condition (CHD) AEB need for close nutrition monitoring, nutrition support and specialized formula. • Altered GI function r/t CHD, PGEs AEB need for TPN and trophic feeds.

  17. Interventions, Goals, Monitoring, and Evaluation • 10/15: 9ml Q 3hrs breast milk and 20kcal/oz formula • 10/15: Parenteral formula/solution • 10/22: 24kcal/ozEnfaport @ 18ml/hr • 10/30: 27kcal/ozEnfaport @ 19ml/hr • Goal: Provide age/condition appropriate nutrition to regain birth weight by 10-14 days, then gain 25-35 gm/d thereafter. • 24kcal/ozEnfaport @ 22ml/hr • 27kcal/ozEnfaport @ 19ml/hr • Monitoring and Evaluation: • Growth • Tolerance • Labs

  18. Conclusion • 16 day old female with aortic coarctation, developed a chylothorax • At goal on feeds of 27kcal Enfaport • Prognosis: Good • Discharged 11/3 to home with parents • Home formula orders: • 27kcal/ozEnfaport, 60ml Q 3hrs until 12/3/13 • Change to Similac 27 kcal/oz

  19. References • Venes D. Taber’s Cyclopedic Medical Dictionary. Philadelphia PA: F.A. Davis Company; 2005. • Porter RS, Kaplan JL. The Merck Manual. Whitehouse Station NJ: Merck Sharp and Dohme Corp.; 2011. • Samour PQ, King K. Pediatric Nutrition. Sadbury, Ma: Jones and Bartlett Learning; 2012. • Tate SS. Anatomy and Physiology. New York NY: McGraw-Hill; 2008.

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