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 • 1.5-4 L of chyle flows through the thoracic duct every day 2 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 system 2

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 condition 2

Causes of Chyle Leaks

5,6 • 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 Leaks

5,6 • 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, dypsnea 1 • 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 fasting 4

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 TID 5 , adjusted for renal impairment and liver disease Surgical repair (Thoracic/Lymphatic Duct Ligation) • Indicated for nutritionally depleted patients, especially patients with esophageal disease 11 • 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 period 9

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 healing 2,5 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 malnutrition 5 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

Calories Total Fat %Cal from Fat MCT Price

Vivonex RTF @95 ml/hr Vivonex RTF (250 ml)

2090 24.2 g 10% 40% 9.7 g 146 ml 250 2.9 g 10% 40% 1.2 g 18 ml

Peptamen 1.5* (250 ml)

375 14 g 33% 70% 9.8 g 147 ml

Vital 1.5 (250 ml)

356 13.5 g 33% 47.5% 6.4 g 96 ml

Vital HN* (300 ml) Powder

300 3.3 g 9.5% 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) MCT Oil contains 8.3 calories per gram (1 Tb = 15 mL = 115 kcal).

Chest Tube Output with TG > 100 mg/dL or 50 110 with high concentration of chylomicrons Existing Malnutrition?

High Chest Tube Output?

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 Yes: NPO with TPN After 5-day trial, Is output decreasing and <1500 ml/day?

9 Consider Adding Octreotide 3,7 No: Low-fat/Fat-free Oral Diet OR TF with high percentage of fat from MCT Oil Is chyle flow decreasing?

No 7 Yes: Begin feeding No: Consider surgical repair after 1-2 weeks 11 or if malnutrition develops 2 Yes: Continue Current Nutrition Plan Discharge to Home on a Low fat Diet with Outpatient follow up

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: April 10

th

– May 22

nd

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”) Wt: 70.5 kg (Weight stable) IBW: 72.7 kg (97% of IBW) 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

Day 10 Chest tube placed 2/2 Pleural effusion Increase Vivonex to Goal Rate Day 15 MBS, SLP Rec’d Mech. Soft Diet Pleural fluid TG > 110 mg/dl Insufficient Calorie Count Data ~ 0% of needs Day 20 Day 25 Pigtail removed, TF changed to Nepro Day 30  Pleural fluid TG, change TF to Vivonex & Add MCT Oil D/C MCT Oil Initiate Mech. Soft, Low Fat Diet, TF to meet > 90% of needs Initiate Calorie Count Pigtail clamped

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 Labs 131 4.6

103 20 34 0.74

100 9 n/a n/a FS: 88-123 I/O= 2890/1622; foley=1620, CT=2

Day 16: Tube Feeding Follow-Up

Labs • • • • • 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

133 106 28 FS: 102-138, 111-118 101 1.6

5.1

17 0.76

I/O =2100/1464; void=1450, CT=14 4.2

Day 20: Tube Feeding Follow-Up

Labs • • • • • 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 9.2

135 114 24 4.8

14 0.96

86 n/a I/O =3705/2610; Texas=2340, CT=70, rectal tube=200 n/a

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

∅ Intake

Day 22

3 Spoonfuls of Applesauce with Meds

Day 23

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 Labs • • • 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 9.7

137 117 20 4.2

10 1.02

120 n/a I/O = 1770/2850; Texas=2750, CT=100 n/a

Day 27: Tube Feeding Follow-Up

Labs • • • • 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) 11 133 113 33 96 1.7

I/O = 2155/1850; CT clamped 4.9

14 0.77

3.7

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 4.2

115 14 37 1.13

109 10.6

n/a n/a FS: 110-140 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: 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)

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: 1138 1142.

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 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

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

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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.

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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.

Selle, J.G., Snyder, W.H., Schreiber, J.T. Chylothorax: Indications for Surgery. Ann Surg. 1971; 177: 245-249.

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Valentine, V.G., Raffin, T.A. The Management of Chylothorax. Chest. 1992; 102: 586-591