Post‐Operative Chylothorax Management Guidelines for the CVICU High Volume Chylous Output (> 15 ml/kg/day) Low volume Chylous Output Inclusion Criteria: Postoperative Cardiac Surgical Diagnosis (< 15 ml/kg/day) Patient. Diagnosis of Chylothorax confirmed as per Pleural Fluid aspiration diagnostic criteria listed. TG level > 100 (or higher than Establish PICC line Exclusion Criteria: Patients with allergy to MCT serum TG) Family meeting with projected time line formula. Patients with gastrointestinal disease that Fluid – TG level, cell count and Chylothorax Diet x 7 days require prolonged NPO. differential *Refer to chylothorax nutrition guidelines Obtain ECHO Serum – TG level, Transferrin, Evaluate for Stenosis/Thrombus/ for details Pre‐Albumin, CRP Collaterals Consider Sildenafil, ACE inhibitors Decreased Chest Tube Output NO Maximize diuretics and fluid restrict If Echo show major area stenosis or *Consider AT III, YES obstructions consider further imaging NPO + TPN/Lipids/* fibrinogen and (CT Angiogram) or cardiac catheterization 7 – 10 days immunoglobulin replacement if clinically Chylothorax Diet indicated For min of 8 weeks from surgical date YES Change PleuraVac to portable CT drain Decrease CT Output < 15 ml/kg/day Decreased CT output NO If > 15 ml/kg/day NO YES Consider lymphatic team evaluation Consider cardiac cath Consider Discharge Home When CT output is < 3ml/kg/day with portable CT system Decreased CT Output YES < 15 ml/kg/day Remove CT when output < 2 ml/kg/day* NO Evaluate Nutritional Status Post Treatment NPO + TPN *Refer to Nutritional Handouts Add Octreotide X 7 days Consider steroids, propranolol, and increase *Upon CT removal, must continue chylothorax diet for PEEP if ventilated minimum of 6 weeks YES Decrease CT Output Chylothorax diet order set includes: < 15 ml/kg/day Low fat diet (10g per day) High medium chain triglycerides (MCT) Low long chain triglycerides (LCT) NPO + TPN/Lipids NO Minimum 4 days Copyright © 2019 CHOC Children’s Hospital Approved EBM Thoracic Duct Ligation/Pleurodesis Committee 1‐20‐2016; Reassess the appropriateness of Care Guidelines as condition changes. This guideline is a tool to aid clinical decision Approximately 3 – 4 weeks post op Revised 9/18/2019 making. It is not a standard of care. The provider should deviate from the guideline when clinical judgment so indicates. References for Chylothorax Guideline Chan EH, Russell JL, Williams WG, Van Arsdell GS, Coles JG, McCrindle BW. Postoperative chylothorax after cardiothoracic surgery in children. Ann Thorac Surg. 2005; 80(5):1864-1870. doi:10.1016/j.athoracsur.2005.04.048. Hoskote AU, Ramaiah RN, Cale CM, Hartley JC, Brown KL. Role of immunoglobulin supplementation for secondary immunodeficiency associated with chylothorax after pediatric cardiothoracic surgery. Pediatr Crit Care Med. 2012;13(5):535-541. doi:10.1097/ PCC.0b013e318241793d. Mery CM, Moffett BS, Khan MS, Zhang W, Guzman-Pruneda FA, Fraser CD, Cabrera AG. Incidence and treatment of chylothorax after cardiac surgery in children: Analysis of a large multi-institution database. J Thorac Cardiovasc Surg. 2014:147(2): 678-686 e1; discussion 685-686. doi:10.1016/j.jtcvs.2013.09.068. Milonakis M, Chatzis, AC, Giannopoulos, NM, Contrafouris, C, Bobos, D, Kirvassilis GV, Sarris GE. Etiology and management of chylothorax following pediatric heart surgery. J Card Surg. 2009; 24: 369-373. doi:10.1111/j.1540-8191.2008.00781.x Savla JJ, Itkin MI, Rossano JW, Dori Y. Post-operative chylothorax in patients with congenital heart disease. J Am Coll Cardiol. 2017; 69(19):2410-2422. doi:10.1016/j.jacc.2017.03.021. White SC, Seckeler MD, McCulloch MA, Buck ML, Hoke TR, Haizlip JA. Patients with single ventricle anatomy may respond better to octreotide therapy for chylothorax after congenital heart surgery. J Card Surg. 2014;29:259-264. doi:10.1111/jocs.12263. Yeh J, Brown ER, Kellogg KA, Donohue JE, Yu S, Gaies MG, Fifer CG, Hirsch JC, Aiyagari R. Utility of a clinical practice guideline in treatment of chylothorax in the postoperative congenital heart patient. Ann Thorac Surg. 2013;96(3):930-936. doi:10.1016/ j.athoracsur.2013.05.058..