In this section
Note: This guideline is currently under review. Introduction
Definition of terms
Diagnosis and Assessment
Chylothorax on Butterfly Ward
Chylothorax is characterised by the accumulation of chyle, a lipid and protein rich fluid within the pleural space. It often occurs due to thoracic duct trauma which can be caused by increased pressures. On Koala, this postoperative complication is often seen post cardiac surgery in patients with redivac drains insitu. Chlothorax is often characterised by a change in drainage appearance (from haemoserous to a thick, opaque and yellow texture), an increase in drainage output (particularly with the consumption of fatty foods), an increase in triglyceride levels and elevated respirations with more laboured work of breathing. Chylothorax may also be associated: tumours (lymphoma, teratomas or Wilms), chest trauma, congenital chylothorax, congenital lymphatic malformations and syndromes (such as Down Syndrome or Noonan Syndrome).
To guide the detection of chylothorax as well promote its management in a safe and effective manner amongst nursing and medical staff.
Ongoing losses of chyle can result in:
(See Figure 1)
A chest drain (either underwater seal drain or redivac) will be inserted into the pleural space. The pleural fluid drained will be assessed for chyle using the following indicators:
(See Figure 2)Treatment is comprised of conservative and surgical interventions as listed below:
In conjunction with both conservative and invasive treatments, the following are to be adhered to:
Figure 2: Management of Chylothorax – The management plan below is to be followed in conjunction with the patient observations listed above. Blue - Conservative treatment; Orange – Invasive treatment; Green – Surgical Treatment. *If the patient has a cow’s milk protein intolerance, further dietician input is required in order to prescribe an alternative formula.
For patients on Butterfly, who are typically sicker and who have diverse causes for chylothorax, approaches differ. Typically, these include fasting (with TPN), replacement of chylous pleural losses exceeding 50mL/kg/day (typically replacing 50% of the losses with 4% albumin every 4 hours), fluid restriction, ocreotide infusion and management of hypogammaglobinaemia with immunoglobulin transfusion. In the setting of diastolic cardiac dysfunction, inotropes are sometimes used. Depending on the cause, most patients eventually respond to medical management and do not require surgical interventions such as thoracic duct ligation or pleurodesis. Figure 2 is not applicable to these patients. Observations should be adhered to as described in the patient observations section above and should include continuous cardiac monitoring.
In terms of medical management, a trial of octreotide should be considered.
Ongoing management, special considerations and potential complications
1. Australian Medicines Handbook (AMH). Available online from: https://childrens. amh.net.au/ monographs/octreotide2. Ascenzi, J.A (2007). Update on Complications of Pediatric Cardiac Surgery. Critical care nursing clinics of North America. 15 (9), 361 – 369.3. Bulut, O et al. (2005). Treatment of chylothorax developed after Congenital Heart Disease surgery: a case report. North Clin Istanbul. 2(3): 227-230.4. Biewer, E.S et al. (2010). Chylothrorax after surgery on congenital heart disease in newborns and infants – Risk factors and efficacy of MCT-diet. Journal of Cardiothoracic Surgery. 5(127), 1-7.5. Czobor, N.R. et al. (2017). Chylothorax after paediatric cardiac surgery complications. Journal of thoracic disease. 9(8), 2466 – 2475.6. Chan, E.H. et al. (2005). Postoperative chylothorax after cardiothoracic surgery in children. Ann Thorac Surg. 80: 1864 – 71.7. Das, A & Shah, P.S. (2010). Octreotide for the treatment of chylothorax in neonates. Cochrane Database Syst Rev. 8 (9). 1-18.8. Haines, C. et al. (2014). Chylothorax development in infants and children in the UK. Arch Dis Children. 99 (11), 724-730. 9. Mery et al. (2014). Incidence and Treatment of Chylothorax After Cardiac Surgery in Children: Analysis of a Large Multi-Institution Database. The Journal of Thoracic and Cardiovascular Surgery, 47 (2), 678-686.10. Milonakis, M et al. (2009). Etiology and management of chylothorax following paediatric heart surgery. Journal of Cardiac Surgery. 24 (8); 369 – 373.11. Panthongviriyakul, C. and Bines, J.E. (2008). Post-operative chylothorax in children: An evidence-based management algorithm. Journal of Paediatrics and Child Health, 44 (12), 716-721.12. Tutor, J.D. (2013). Chylothorax in Infants and Children. Pediatrics, 133, 722-733.
Chylothorax management evidence table.
Please remember to read the disclaimer.The development of this nursing guideline was coordinated by Charmaine Cini, RN, Platypus, and Alison Kendrick, Educator, Butterfly, approved by the Nursing Clinical Effectiveness Committee. First published July 2019.