CHYLOTHORAX. Why you don't want to see it nor do we know how to treat it. Vijay Anand, MD FRCPC
|
|
- Wendy Teresa Jackson
- 6 years ago
- Views:
Transcription
1 CHYLOTHORAX Why you don't want to see it nor do we know how to treat it Vijay Anand, MD FRCPC
2 DISCLOSURES None
3 THANK YOU Jason Buckley and the PC4
4 CHYLOTHORAX WHY WE DON T WANT TO SEE IT
5 CHYOTHORAX You ve just finished managing a Norwood, complex hetertoaxy, (etc) after a rocky few days You ve started feeding as extubation is still a few days away You re ready to handover to the daytime intensivist, when you get called to the bedside and get handed
6 CHYOTHORAX Why is this a big deal?
7 OUTCOMES ICU LOS Chylothorax No Chylothorax McCulloch et al. (2008) 38.7 ± ± 6.7 Bauman et al. (2013) 6 (1, 61) 2.5* Ismail et al. (2014) 12 ± ± 9 White et al. (2014) 40.5 (26, 64.5) 7 (4, 15) 18 (7-42) 3 (2-7) LENGTH OF STAY IN DAYS Buckley et al. Manuscript in Submission
8 OUTCOMES HOSPITAL LOS PHIS DATABASE Chylothorax No Chylothorax Neonates 47 (30-74) 20 (13-36) Infants 17 (9-36) 7 (5-13) Young Children 17 (10-30) 5 (3-9) Older Children 14 (6-27) 4 (3-6) Teenagers 10 (7-41) 5 (4-7) 30 (15-57) 7 (4-13) LENGTH OF STAY IN DAYS Buckley et al. Manuscript in Submission Mery et al. (2014) The Journal of Thoracic and Cardiovascular Surgery. 147(2)
9 CHYOTHORAX What causes the increased length of stay Total Protein Albumin Globulin Fibrinogen Fat Electrolytes AMOUNT g/l g/l g/l mg/l g/l [Plasma] Mallick and Bodenham. British Journal of Anaesthesia. 2003: 91(2):
10 OUTCOMES MORBIDITY Chylothora x No Chylothorax p value Pneumonia 3% 1% Urinary Tract Infection 6% 1% < Bloodstream Infection 5% 1% < Surgical Site Infection 3% 1% < Surgical Site Infection (Deep) 1% Buckley et al. Manuscript in Submission
11 OUTCOMES COST PHIS DATABASE Chylothorax No Chylothorax Neonates 210 ( ) 99 (63-165) Infants 82 (48-160) 42 (30-69) Young Children 74 (47-127) 34 (24-53) Older Children 59 (26-162) 35 (25-53) Teenagers 50 (32-198) 41 (30-62) P= < COST (1000US) Mery et al. (2014) The Journal of Thoracic and Cardiovascular Surgery. 147(2)
12 OUTCOMES MORTALITY PHIS DATABASE Chylothorax No Chylothorax Neonates 11.3% 4.8% Infants 4.3% 1% Young Children 1.1% 0.5% Older Children 1.7% 0.5% Teenagers 0% 0.45% OVERALL MORTALITY FOR PATIENTS WITH CHYLOTHORAX 5.9% 10% Buckley et al. Manuscript in Submission Mery et al. (2014) The Journal of Thoracic and Cardiovascular Surgery. 147(2)
13 CHYLOTHORAX Longer hospital length of stay Longer ICU length of stay Higher mortality Higher costs More infections We must be getting better though right?
14 INCIDENCE OVER TIME INCIDENCE OF CHYLOTHORAX PHIS DATABASE 3.8% Buckley et al. Manuscript in Submission Mery et al. (2014) The Journal of Thoracic and Cardiovascular Surgery. 147(2)
15 CHYLOTHORAX Hospital length of stay increasing ICU length of stay higher Mortality increasing Costs increasing More infections And we are seeing it more
16 THAT S WHY WE DON T T TO SEE IT EVEN THOUGH WE A
17 BUT HOW DO WE TREAT IT?
18 TREATMENT PROTOCOLS OF TREATMENT Several published Variation between protocols Those studied showed decrease in hospital resource utilization Wide variation in timing So what are we actually doing?
19
20 TREATMENT PROTOCOLS OF TREATMENT Informal Survey of CICUs Themes Lots of frustration Inconsistency Protocol inconsistency Variations on published protocols
21 DEFINITION Cardiology in the Young Sep 29: 1-10
22 DEFINITION Milky appearance WBC >1000 cells/μl Lymphocytes >80% Pleural:Serum Triglyceride Level >1 Triglyceride level >1.1mmol/L Presence of lymphatic fluid in the pleural space, commonly secondary to leakage from the thoracic duct or one of its main tributaries. Thoracocentesis is the gold standard for diagnosis and generally reveals a predominance of lymphocytes and/or a triglyceride level greater than 110 mg/dl Brown et al. Cardiology in the Young Sep 29: 1-10
23 DEFINITION BROWN ET AL (2016) PROTOCOLS Milky appearance Little comment WBC >1000 cells/μl (universally agreed) Universally agreed Lymphocytes >80% 75-90% Pleural:Serum >1 Universally agreed Triglyceride level >1.1mmol/L >1.0 Brown et al. Cardiology in the Young Sep 29: 1-10
24 PROTOCOLS CHYLOTHORAX CONFIRMED LOW HIGH 3, 5, 10, 20, 50 ml/kg/day
25 PROTOCOLS CHYLOTHORAX CONFIRMED LOW HIGH 3, 5, 10, 20, 50 ml/kg/day
26 PROTOCOLS CHYLOTHORAX CONFIRMED LOW HIGH
27 PROTOCOLS LOW : FIRST STEP Diet Change Medium Chain Triglyceride Formula Defatted Milk (DFM) Length of Diet Change 3 12 weeks Mostly 4-6 weeks LOW CHYLOTHORAX CONFIRMED HIGH TPN + NPO TPN + NPO + OCTREOTIDE SURGICAL INTERVENTI ON
28 PROTOCOLS LOW : SECOND (?) STEP If at any point in time the output passed the threshold for low output into high output, switched arms to the high volume arm LOW CHYLOTHORAX CONFIRMED HIGH TPN + NPO TPN + NPO + OCTREOTIDE SURGICAL INTERVENTI ON
29 PROTOCOLS HIGH : FIRST STEP Diet Change Medium Chain Triglyceride Formula Defatted Milk (DFM) Length of Diet Change 24 hours to 21 days LOW CHYLOTHORAX CONFIRMED HIGH TPN + NPO TPN + NPO + OCTREOTIDE SURGICAL INTERVENTI ON
30 PROTOCOLS HIGH : SECOND STEP Total Parenteral Nutrition NPO LOW CHYLOTHORAX CONFIRMED HIGH Length in this phase 5 days to 3 weeks TPN + NPO TPN + NPO + OCTREOTIDE SURGICAL INTERVENTI ON
31 PROTOCOLS HIGH : THIRD STEP Total Parenteral Nutrition + Octreotide Other Options: Steroids (not consistent) Milrinone (not consistent) Sildenafil (not consistent) Anticoagulation (not consistent) LOW CHYLOTHORAX CONFIRMED HIGH TPN + NPO TPN + NPO + OCTREOTIDE SURGICAL INTERVENTI ON
32 OCTREOTIDE OCTREOTIDE Dose range of mcg/kg/hr Side effects: Abdominal distension Diarrhea Necrotizing enterocolitis Transient hypoglycemia/transient hypothyroidism No practice recommendation was made LOW CHYLOTHORAX CONFIRMED HIGH TPN + NPO TPN + NPO + OCTREOTIDE SURGICAL INTERVENTI ON Das and Shah. Cochrane Database of Systematic Reviews 2010, Issue 9
33 OCTREOTIDE OCTREOTIDE Since 2010 Multiple single institution case series published with success rate of 50-80% Decreasing use in PHIS database (24% in 2004 to 13% in 2011, p=0.034) 1 The only treatment strategy to change over time LOW CHYLOTHORAX CONFIRMED HIGH TPN + NPO TPN + NPO + OCTREOTIDE SURGICAL INTERVENTI ON 1 Mery et al. (2014) The Journal of Thoracic and Cardiovascular Surgery. 147(2)
34 PROTOCOLS HIGH : THIRD STEP Total Parenteral Nutrition + Octreotide Dose Range 1-12 mcg/kg/hr Escalating doses? Length in this phase 3 days to 17 days Wean? LOW CHYLOTHORAX CONFIRMED HIGH TPN + NPO TPN + NPO + OCTREOTIDE SURGICAL INTERVENTI ON
35 PROTOCOLS HIGH : FOURTH STEP Intervention Thoracic Duct Ligation Pleurodesis Catheter Intervention LOW CHYLOTHORAX CONFIRMED HIGH TPN + NPO TPN + NPO + OCTREOTIDE SURGICAL INTERVENTI ON
36 INTERVENTION THORACIC DUCT LIGATION CHYLOTHORAX CONFIRMED LOW HIGH Ann Thorac Surg Jul;88(1): TPN + NPO TPN + NPO + OCTREOTIDE SURGICAL INTERVENTI ON
37 INTERVENTION THORACIC DUCT LIGATION 20 patients 18 patients had resolution Range of time to intervention: days No pre-ligation protocol Has become the mainstay surgical option for chylothorax But there is hesitancy LOW CHYLOTHORAX CONFIRMED HIGH TPN + NPO TPN + NPO + OCTREOTIDE SURGICAL INTERVENTI ON Nath et al. Annals of Thoracic Surgery 2009 Jul;88(1):246-51
38 THORACIC DUCT LIGATION CHYLOTHORAX CONFIRMED LOW HIGH Variation in path of the thoracic duct Unnecessary surgery Need for reoperation TPN + NPO TPN + NPO + OCTREOTIDE SURGICAL INTERVENTI ON
39 RATES IN BENCHMARK OPS RATE (%) FONTAN 9.38 NORWOOD 8.51 ASO/VSD 8.38 AVC 8.02 GLENN 7.08 ASO 7.02 RATE (%) TRUNCUS 4.91 TOF 4.35 COARCTATION 3.55 REPAIR BT SHUNT 2.92 VSD 1.31 Mavroudis et al. Annals of Thoracic Surgery May; 97(5):
40 INTERVENTION THE THORACIC DUCT If not surgery then what? LOW CHYLOTHORAX CONFIRMED HIGH TPN + NPO TPN + NPO + OCTREOTIDE SURGICAL INTERVENTI ON 1 Mery et al. (2014) The Journal of Thoracic and Cardiovascular Surgery. 147(2)
41 INTERVENTION CHYLOTHORAX CONFIRMED LOW HIGH TPN + NPO TPN + NPO + OCTREOTIDE SURGICAL INTERVENTI ON
42 PROTOCOLS Itkin et al JTCVS (3):
43 PROTOCOLS CHYLOTHORAX CONFIRMED LOW HIGH TPN + NPO TPN + NPO + OCTREOTIDE SURGICAL INTERVENTI ON
44 PROTOCOLS DORI ET AL (2016) Demonstrated successful cannulation of cysterna chyli Successful embolization Same method for traumatic chylous leaks
45 3 YO HLHS S/P TCPC 3 MO IN HOSPITAL RESPIRATORY DISTRESS AND PERSISTENT LEAK.
46 INTERVENTION CATHETERIZATION Offers non-surgical approach Complications Transient abdominal pain (10/18) Transient hypotension (14/18) Bleeding? Stay tuned
47 BACK TO PROTOCOLS WHAT ABOUT IMAGING? ECHO Assess RVSP SVC Assessment Upper extremity ultrasound Potential clots LOW CHYLOTHORAX CONFIRMED HIGH TPN + NPO TPN + NPO + OCTREOTIDE SURGICAL INTERVENTI ON
48 PROTOCOLS POST-SUCCESSFUL INTERVENTION MCT/Low Fat Diet? TPN + NPO? LOW CHYLOTHORAX CONFIRMED HIGH Most protocols opt for MCT/Low Fat Diet TPN + NPO TPN + NPO + OCTREOTIDE SURGICAL INTERVENTI ON
49 CHYLOTHORAX CONFIRMED VARIATION OF 9 DAYS 59 DAYS LOW 3, 5, 10, 20, 50 ml/kg/day HIGH DAYS 1-21 DAYS TPN + NPO 5-21 DAYS TPN + NPO + OCTREOTIDE 3-17 DAYS SURGICAL INTERVENTION DUCT LIGATION PLEURODESIS CATHETER INTERVENTION Summary of feedback from over 20 protocols and 50+ CICUs
50 OTHER QUESTIONS Low output persistent chylothorax
51 CHYLOTHORAX CONFIRMED VARIATION OF 9 DAYS 59 DAYS LOW 3, 5, 10, 20, 50 ml/kg/day HIGH DAYS 1-21 DAYS TPN + NPO 5-21 DAYS TPN + NPO + OCTREOTIDE 3-17 DAYS SURGICAL INTERVENTION DUCT LIGATION PLEURODESIS CATHETER INTERVENTION Summary of feedback from over 20 protocols and 50+ CICUs
52 WHAT S BEING STUDIED NOW? CURRENT RESEARCH Search of trials registry 10 studies 4 recruiting Most studies are about formula type
53 WHAT S NEXT WHAT DO WE DO NEXT? Clinical Trial with Protocol Melissa.Winder@imail.org David.bailly@hsc.utah.edu Randomized Controlled Trial in the OR Role of the PCICS
54 SUMMARY Why we don t want to see chylothorax is clear We kind of sort of know what we are doing Wide degree of variation in practice Some innovative treatment options on the horizon
55 THANK YOU
Incidence and treatment of chylothorax after cardiac surgery in children: analysis of a large multi-institutional database. Carlos M.
Incidence and treatment of chylothorax after cardiac surgery in children: analysis of a large multi-institutional database Carlos M. Mery, MD, MPH Assistant Professor, and Pediatrics Congenital Heart Texas
More informationChildren with Single Ventricle Physiology: The Possibilities
Children with Single Ventricle Physiology: The Possibilities William I. Douglas, M.D. Pediatric Cardiovascular Surgery Children s Memorial Hermann Hospital The University of Texas Health Science Center
More informationChylothorax post cardiac surgery
Chylothorax post cardiac surgery Introduction Chylothorax is the accumulation of lymphatic fluid (chyle) within pleural space. The most common cause in paediatric population is post-operative chylothorax,
More informationCongenital Chylothorax
Case Study TheScientificWorldJOURNAL (2009) 9, 431 434 ISSN 1537-744X; DOI 10.1100/tsw.2009.62 Congenital Chylothorax Saad Lahmiti*, Jamila Elhoudzi, Salwa Baki, and Abdelmounaim Aboussad Neonatal Intensive
More informationIncidence and treatment of chylothorax after cardiac surgery in children: Analysis of a large multi-institution database
Congenital Heart Disease Mery et al Incidence and treatment of chylothorax after cardiac surgery in children: Analysis of a large multi-institution database Carlos M. Mery, MD, MPH, a,b Brady S. Moffett,
More informationWhat Can the Database Tell Us About Reoperation?
AATS/STS Congenital Heart Disease Postgraduate Symposium May 5, 2013 What Can the Database Tell Us About Reoperation? Jeffrey P. Jacobs, M.D. All Children s Hospital Johns Hopkins Medicine The Congenital
More informationUtility of a Clinical Practice Guideline in Treatment of Chylothorax in the Postoperative Congenital Heart Patient
Utility of a Clinical Practice Guideline in Treatment of Chylothorax in the Postoperative Congenital Heart Patient Jay Yeh, MD, Erin R. Brown, RD, Kimberly A. Kellogg, MS, CPNP, Janet E. Donohue, MPH,
More informationPost-Operative Chylous Ascites. David Kashan, PGY-4 Richmond University Medical Center 7/30/15
Post-Operative Chylous Ascites David Kashan, PGY-4 Richmond University Medical Center 7/30/15 HPI Patient is a 76 year old female p/w one day of worsening abdominal pain, +N/V, fevers and chills HPI PMHx:
More informationNUTRITIONAL MANAGEMENT OF CHYLOTHORAX. Lekha.V.S Senior Clinical Dietitian HOD- Department Of Dietetics Apollo Children's Hospital
NUTRITIONAL MANAGEMENT OF CHYLOTHORAX Lekha.V.S Senior Clinical Dietitian HOD- Department Of Dietetics Apollo Children's Hospital INTRODUCTION Nutrition therapy is a key component in the care of patients
More informationTrauma Activation 7/18/17
Blunt Rupture of the Thoracic Duct after Severe Thoracic Trauma Samuel Brown, MD Trauma Activation 7/18/17 53 year old male, rear end MVC, exited vehicle and was struck by a semi truck. Denies LOC, complaints
More informationMANAGEMENT OF LATE PRESENTATION OF CONGENITAL HEART DESEASE
MANAGEMENT OF LATE PRESENTATION OF CONGENITAL HEART DESEASE Guillermo E. Moreno Pediatric Cardiac Intensive Care Unit (UCI35) Hospital de Pediatría Dr. Juan P. Garrahan Buenos Aires - Argentina Non financial
More informationCase report description of a collaborative approach to thoracic duct embolization in patients with congenital heart disease
Luangrath et al. Journal of Congenital Cardiology (2018)2:2 https://doi.org/10.1186/s40949-018-0016-z Journal of Congenital Cardiology CASE REPORT Open Access Case report description of a collaborative
More informationGlenn Shunts Revisited
Glenn Shunts Revisited What is a Super Glenn Patricia O Brien, MSN, CPNP-AC Nurse Practitioner, Pediatric Cardiology No Disclosures Single Ventricle Anatomy Glenn Shunt Cavopulmonary Anastomosis Anastomosis
More informationInterventional Management of Lymphatic Morbidity in Patients With CHD
Interventional Management of Lymphatic Morbidity in Patients With CHD Maxim Itkin MD, FSIR Professor of Radiology and Pediatrics Hospital of University of Pennsylvania DISCLOSURE STATEMENT OF FINANCIAL
More informationCHYLOTHORAX: PICU PERSPECTIVE
CHYLOTHORAX: PICU PERSPECTIVE DR. P. S. BHATTACHARYYA CONSULTANT PAEDIATRIC INTENSIVIST APOLLO GLENEAGLES CHILDREN S CENTRE APOLLO GLENEAGLES HOSPITALS, KOLKATA DISCLAIMER: INTERPRETATION IS ALL YOURS
More informationino in neonates with cardiac disorders
ino in neonates with cardiac disorders Duncan Macrae Paediatric Critical Care Terminology PAP Pulmonary artery pressure PVR Pulmonary vascular resistance PHT Pulmonary hypertension - PAP > 25, PVR >3,
More informationRisk Factor Evaluation for Thrombosis and Bleeding in Pediatric Patients with Heart Disease
Risk Factor Evaluation for Thrombosis and Bleeding in Pediatric Patients with Heart Disease Kristen Nelson, MD Johns Hopkins University Director, Pediatric Cardiac Critical Care Why Does it Matter? Pediatric
More informationDirector of HUP/CHOP Center for Lymphatic Imaging and Interventions
Introduction Lymphatic Interventions: The Real Next Frontier Associate Professor of Radiology and Pediatrics Maxim Itkin MD, FSIR Director of HUP/CHOP Center for Lymphatic Imaging and Interventions Physiology
More informationManagement of a Patient after the Bidirectional Glenn
Management of a Patient after the Bidirectional Glenn Melissa B. Jones MSN, APRN, CPNP-AC CICU Nurse Practitioner Children s National Health System Washington, DC No Disclosures Objectives qbriefly describe
More informationDown Syndrome Medical Interest Group Friday, 12 June Cardiac Surgery in patients with Down Syndrome
Down Syndrome Medical Interest Group Friday, 12 June 2015 Cardiac Surgery in patients with Down Syndrome Mr. Attilio Lotto, FRCS CTh Congenital Cardiac Surgeon Cardiac surgery in patients with Down syndrome
More informationPrenatal and Postnatal Evaluation of Lymphatic Disorders
Prenatal and Postnatal Evaluation of Lymphatic Disorders David M Biko, MD Director, Section of Cardiovascular and Lymphatic Imaging Children s Hospital of Philadelphia Assistant Professor of Radiology
More informationClinical Medicine Insights: Cardiology
Clinical Medicine Insights: Cardiology Case report Open Access Full open access to this and thousands of other papers at http://www.la-press.com. Stent Implantation for Effective Treatment of Refractory
More informationChylothorax Basics OVERVIEW GENETICS SIGNALMENT/DESCRIPTION OF PET
Chylothorax Basics OVERVIEW Chylo- refers to chyle; thorax refers to the chest Chyle is a milky to slightly yellow fluid composed of lymph and fats (rich in triglycerides) taken up from the intestines
More informationHigh-volume bilateral chylothorax presenting with hypoxemia and shock in a pediatric patient following tracheostomy revision: a case report
Thatcher et al. Journal of Medical Case Reports (2015) 9:235 DOI 10.1186/s13256-015-0721-6 CASE REPORT JOURNAL OF MEDICAL CASE REPORTS Open Access High-volume bilateral chylothorax presenting with hypoxemia
More informationThoracic Duct Embolization Technique & Results
Thoracic Duct Embolization Technique & Results Edward W. Lee, MD, PhD, MSc Assistant Professor Director of Research Interventional Radiology Department of Radiology AGA AASLD JCCC CTSI CCTP TRIC AACR UCLA
More informationTRANSFUSION GUIDELINES FOR CARDIOTHORACIC UNIT 2006
TRANSFUSION GUIDELINES FOR CARDIOTHORACIC UNIT 2006 CTU blood product transfusion guidelines 2006 1 Summary of guidelines RED CELLS (10-15ml/kg) This applies to ward patients / icu patients who are stable.
More informationUNDERSTANDING CHYLE IN CATS
Vet Times The website for the veterinary profession https://www.vettimes.co.uk UNDERSTANDING CHYLE IN CATS Author : DAN FORSTER Categories : Vets Date : February 11, 2008 DAN FORSTER discusses diagnosis
More informationSurgical Approaches to Advanced Pulmonary Vascular Disease. Historical Perspectives. Historical Perspectives
5 th International Conference Neonatal and Childhood Pulmonary Vascular Disease, San Francisco, March 9-10, 2012 Surgical Approaches to Advanced Pulmonary Vascular Disease William M. Novick, M.D., M.S.
More informationChylothorax can occur after any surgery performed in the vicinity
Alaa Basiouni S et all Chylothorax after surgery for congenital heart disease in children: a retrospective observational study Alaa Basiouni S MD Sameh Ibrahim MD Background: Chylothorax in children after
More informationCongenital Cardiac Anesthesia as a Specialty: Where We ve Been & Where We re Going
Congenital Cardiac Anesthesia as a Specialty: Where We ve Been & Where We re Going A Septuagenarian Perspective Paul R. Hickey, MD Professor & Chair, Department of Anaesthesia, Harvard Medical School Anesthesiologist-in-Chief,
More informationCONGENITAL CHYLOTHORAX OF THE NEWBORN: DIAGNOSIS AND TREATMENT IN THREE PICTURES
150 Lymphology 49 (2016) 150-156 CONGENITAL CHYLOTHORAX OF THE NEWBORN: DIAGNOSIS AND TREATMENT IN THREE PICTURES C. Bellini, R. Cabano, T. Bellini, F. Boccardo, G. Morcaldi, L.A. Ramenghi Neonatal Intensive
More informationThe Heart Center. Quality Counts: Cardiothoracic Surgery and Interventional Cardiology
The Heart Center Quality Counts: Cardiothoracic Surgery and Interventional Cardiology The Cardiothoracic Surgery Program at Nationwide Children s Hospital is dedicated to the treatment of all patients,
More informationSurgical Management of Lymphatic Complications After Univentricular Heart Repair
Surgical Management of Lymphatic Complications After Univentricular Heart Repair Christian Kreutzer MD Head, Pediatric and congenital Heart Surgery Hospital Universitario Austral. Buenos Aires. Argentina
More informationPerimembranous VSD: When Do We Ask For A Surgical Closure? LI Xin. Department of Cardiothoracic Surgery Queen Mary Hospital Hong Kong
Perimembranous VSD: When Do We Ask For A Surgical Closure? LI Xin Department of Cardiothoracic Surgery Queen Mary Hospital Hong Kong Classification (by Kirklin) I. Subarterial (10%) Outlet, conal, supracristal,
More informationManagement and prevention of chylous leakage after laparoscopic lymphadenectomy
European Review for Medical and Pharmacological Sciences Management and prevention of chylous leakage after laparoscopic lymphadenectomy L.-P. HAN, H.-M. ZHANG, H.-D. ABHA, T. LIU 1, X.-P. ZHANG 2 2014;
More informationSOUTHERN WEST MIDLANDS NEWBORN NETWORK
SOUTHERN WEST MIDLANDS NEWBORN NETWORK Hereford, Worcester, Birmingham, Sandwell & Solihull Title : Person Responsible for Review : Management of Gastro-Intestinal Stomata In Neonates R. Wragg & G.Jawaheer
More informationSurgical Treatment for Double Outlet Right Ventricle. Masakazu Nakao Consultant, Paediatric Cardiothoracic Surgery
for Double Outlet Right Ventricle Masakazu Nakao Consultant, Paediatric Cardiothoracic Surgery 1 History Intraventricular tunnel (Kawashima) First repair of Taussig-Bing anomaly (Kirklin) Taussig-Bing
More informationMechanical Ventilation in Post-Op VSD Problems Encountered and Treatment Solutions in Developing Countries
Mechanical Ventilation in Post-Op VSD Problems Encountered and Treatment Solutions in Developing Countries Casey Culbertson MD Cardiac Intensivist Disclosure #1 Unfortunately Nothing financial Disclosure
More informationA 44-year-old, Caucasian, male. decreased exercise tolerance
Sunita Rai, Alina Andreea Ionescu srai15@doctors.net.uk Respiratory Medicine, Aneurin Bevan University Health Board, Newport, UK. A 44-year-old, Caucasian, male nonsmoker with worsening difficulty in breathing
More informationECMO CPR. Ravi R. Thiagarajan MBBS, MPH. Cardiac Intensive Care Unit
ECMO CPR Ravi R. Thiagarajan MBBS, MPH Staff Intensivist Cardiac Intensive Care Unit Children s Hospital Boston PCICS 2008, Miami, FL No disclosures Disclosures Outline Outcomes for Pediatric in-hospital
More informationOutline. Congenital Heart Disease. Special Considerations for Special Populations: Congenital Heart Disease
Special Considerations for Special Populations: Congenital Heart Disease Valerie Bosco, FNP, EdD Alison Knauth Meadows, MD, PhD University of California San Francisco Adult Congenital Heart Program Outline
More informationECMO: a breakthrough in care for respiratory failure. PD Dr. Thomas Müller Regensburg no conflict of interest
ECMO: a breakthrough in care for respiratory failure? PD Dr. Thomas Müller Regensburg no conflict of interest 1 Overview Mortality of severe ARDS Indication for ECMO PaO 2 /FiO 2 Efficiency of ECMO: gas
More informationMalignant Effusions. Anantham Devanand Respiratory and Critical Care Medicine Singapore General Hospital
Malignant Effusions Anantham Devanand Respiratory and Critical Care Medicine Singapore General Hospital Malignant Effusions Definition: Presence of malignant cells in the pleural space 75% are caused by
More informationSustain Follow-up Data Collection Form (Revised 2/4/2014) (both pediatric and adult elements) (Please select) (Please select)
Patient Information Sustain Follow-up Data Collection Form (Revised 2/4/2014) (both pediatric and adult elements) Visit Date Patient Birth Date -- Gender (please select) What is the nature of this follow-up?
More informationThoracic Duct Embolization for Nontraumatic Chylous Effusion. Gregory J. Nadolski, MD ; and Maxim Itkin, MD
CHEST Thoracic Duct Embolization for Nontraumatic Chylous Effusion Experience in 34 Patients Gregory J. Nadolski, MD ; and Maxim Itkin, MD Original Research DISORDERS OF THE PLEURA Background: Thoracic
More informationIncidence and management of chylothorax after esophagectomy
Thoracic Cancer ISSN 1759-7706 ORIGINAL ARTICLE Incidence and management of chylothorax after esophagectomy Longsheng Miao 1,2, Yawei Zhang 1,2, Hong Hu 1,2, Longfei Ma 1,2, Yihua Shun 1,2, Jiaqing Xiang
More informationPostoperative Chylothorax: the Use of Dynamic Magnetic Resonance Lymphangiography and Thoracic Duct Embolization
pissn 2384-1095 eissn 2384-1109 imri 2018;22:182-186 Postoperative Chylothorax: the Use of Dynamic Magnetic Resonance Lymphangiography and Thoracic Duct Embolization Chae Woon Lee, Hyun Jung Koo, Ji Hoon
More informationScott A. Lynch, MD, MPH,FAAFP Assistant Professor
Scott A. Lynch, MD, MPH,FAAFP Assistant Professor Lynch.Scott@mayo.edu 2015 MFMER 3543652-1 Nutrition in the Hospital Mayo School of Continuous Professional Development 2nd Annual Inpatient Medicine for
More informationWho Needs Parenteral Nutrition? Is Parenteral Nutrition An Appropriate Intervention?
Who Needs Parenteral Nutrition? 1 Is Parenteral Nutrition An Appropriate Intervention? Key questions to ask with initial consultation Can the gastrointestinal (GI) tract be utilized? Can the GI tract be
More informationSurgical management of congenital heart disease: evaluation according to the Aristotle score
European Journal of Cardio-thoracic Surgery 37 (2010) 210 217 www.elsevier.com/locate/ejcts Surgical management of congenital heart disease: evaluation according to the Aristotle score Jutta Heinrichs
More informationNEC- What Lies Under the Big Umbrella?
NEC- What Lies Under the Big Umbrella? Instructor in Surgery Associate Surgical Director, Center for Advanced Intestinal Rehabilitation Department of Surgery, Boston Children's Hospital Harvard Medical
More informationPitfalls of the Pediatric Chest and Abdomen SPR 2017
Pitfalls of the Pediatric Chest and Abdomen SPR 2017 Richard I. Markowitz, MD, FACR Children s Hospital of Philadelphia Perelman School of Medicine University of Pennsylvania No Disclosures Cognitive Perceptual
More informationRegional Prenatal Congenital Heart Disease Detection and Practices Lori Erickson MSN, RN, CPNP-PC Ward Family Heart Center
Regional Prenatal Congenital Heart Disease Detection and Practices Lori Erickson MSN, RN, CPNP-PC Ward Family Heart Center The Children's Mercy Hospital, 2014. 05/14 Objectives Evaluate our regional prenatal
More informationPleural Effusion. Exudative pleural effusion - Involve an increase in capillary permeability and impaired pleural fluid resorption
Pleural Effusion Definition of pleural effusion Accumulation of fluid between the pleural layers Epidemiology of pleural effusion Estimated prevalence of pleural effusion is 320 cases per 100,000 people
More informationHeart Transplantation for Patients with a Fontan Procedure
Heart Transplantation for Patients with a Fontan Procedure Kirk R. Kanter MD Professor of Surgery Pediatric Cardiac Surgery Emory University School of Medicine Children s Healthcare of Atlanta Atlanta,
More informationUnbalanced AVC: When is it Time to Bail?
Unbalanced AVC: When is it Time to Bail? David M. Overman Division of Pediatric Cardiac Surgery The Children s Heart Clinic Chief, Division of Cardiovascular Surgery Children s Hospitals and Clinics of
More informationThe Society for Vascular Surgery Patient Safety Organization: Use of A Quality Registry for Practice Improvement
The Society for Vascular Surgery Patient Safety Organization: Use of A Quality Registry for Practice Improvement Georgia Vascular Society Adam W. Beck, MD, FACS September 9, 2017 Disclosures No relevant
More informationGastrointestinal Feedings Post Op: What s the deal on beginning oral feedings?
Gastrointestinal Feedings Post Op: What s the deal on beginning oral feedings? Kate Willcutts, DCN, RD, CNSC University of Virginia Health System Charlottesville, VA kfw3w@virginia.edu Objectives 1. Discuss
More informationA Case with Tumor, Tuberculosis and Chylothorax
Archives of Clinical and Medical Case Reports doi: 10.26502/acmcr.96550027 Volume 2, Issue 3 A Case with Tumor, Tuberculosis and Chylothorax Case Report Kübra Aşık Cansız 1, Tuncer Tuğ 1, Suat Konuk 1,
More informationThe following content was supplied by the author as supporting material and has not been copy-edited or verified by JBJS.
Page 1 The following content was supplied by the author as supporting material and has not been copy-edited or verified by JBJS. Appendix TABLE E-1 Care-Module Trigger Events That May Indicate an Adverse
More informationChylothorax after pediatric cardiac surgery complicates shortterm but not long-term outcomes a propensity matched analysis
Original Article Chylothorax after pediatric cardiac surgery complicates shortterm but not long-term outcomes a propensity matched analysis Nikoletta R. Czobor 1, György Roth 1, Zsolt Prodán 2, Daniel
More informationManagement of complex CHD in adults
Management of complex CHD in adults Victor Tsang Society of Thoracic Surgeons of Thailand 2016 The impact of infant cardiac surgery Over 90 % of infants born with CHD will reach adulthood By 2010, adults
More informationCardiac Emergencies in Infants. Michael Luceri, DO
Cardiac Emergencies in Infants Michael Luceri, DO October 7, 2017 I have no financial obligations or conflicts of interest to disclose. Objectives Understand the scope of congenital heart disease Recognize
More informationUnderstanding your child s heart. Hypoplastic left heart syndrome
Understanding your child s heart Hypoplastic left heart syndrome 8 bout this book Contents If you re reading this book, you ve probably just had some very upsetting news and have lots of questions running
More informationIs laparoscopic sleeve gastrectomy safer than laparoscopic gastric bypass?
Is laparoscopic sleeve gastrectomy safer than laparoscopic gastric bypass? A comparison of 30-day complications using the MBSAQIP data registry Sandhya B. Kumar MD, Barbara C. Hamilton MD, Soren Jonzzon,
More informationCongenital Heart Disease
Congenital Heart Disease Mohammed Alghamdi, MD, FRCPC, FAAP, FACC Associate Professor and Consultant Pediatric Cardiology, Cardiac Science King Fahad Cardiac Centre King Saud University INTRODUCTION CHD
More informationPARENTERAL NUTRITION
PARENTERAL NUTRITION DEFINITION Parenteral nutrition [(PN) or total parenteral nutrition (TPN)] is the intravenous infusion of some or all nutrients for tissue maintenance, metabolic requirements and growth
More informationAre There Indications for Atrial Switch (or Atrial Inversion Surgery) in the 21st Century? Marcelo B. Jatene
Are There Indications for Atrial Switch (or Atrial Inversion Surgery) in the 21st Century? Marcelo B. Jatene marcelo.jatene@incor.usp.br No disclosures Transposition of Great Arteries in the 21st century
More informationCase Report Chyle Leak following Open Donor Nephrectomy: A Rare Complication A Case Report
Case Reports in Transplantation Volume 2012, Article ID 259838, 4 pages doi:10.1155/2012/259838 Case Report Chyle Leak following Open Donor Nephrectomy: A Rare Complication A Case Report Sandeep Harkar,
More informationPerventricular Closure of Muscular VSD s
Perventricular Closure of Muscular VSD s Dr Damien Kenny, MB, MD Assistant Professor of Pediatrics Director of the Cardiac Catheterization Hybrid Suite Co-Director of the Rush Adult Congenital Heart Disease
More informationAdults with Congenital Heart Disease. Michael E. McConnell MD, Wendy Book MD Teresa Lyle RN NNP
Adults with Congenital Heart Disease Michael E. McConnell MD, Wendy Book MD Teresa Lyle RN NNP Outline History of CHD Statistics Specific lesions (TOF, TGA, Single ventricle) Erythrocytosis Pregnancy History
More informationUnderstanding your child s heart. Pulmonary atresia with intact ventricular septum
Understanding your child s heart Pulmonary atresia with intact ventricular septum 7 About this book Contents If you re reading this book, you ve probably just had some very upsetting news and have lots
More informationPrevention of thrombosis
Prevention of thrombosis Massimo Lamperti MD, MBA Chief of General Anaesthesia Department Anaesthesiology Institute Cleveland Clinic Abu Dhabi Clinical Professor of Anaesthesiology Cleveland Clinic Lerner
More informationPneumothorax. Defined as air in the pleural space which can occur through a number of mechanisms
Pneumothorax Defined as air in the pleural space which can occur through a number of mechanisms Traumatic pneumothorax Penetrating chest trauma Common secondary to bullet or knife penetration Chest tube
More informationQuick Literature Searches
Quick Literature Searches National Pediatric Nighttime Curriculum Written by Leticia Shanley, MD, FAAP Institution: University of Texas Southwestern Medical Center Case 1 It s 1:00am and you have just
More informationThe complications of cardiac surgery:
The complications of cardiac surgery: a walk on the Dark Side? Prof Rik De Decker Red Cross Children s Hospital CME Nov/Dec 2011 http://www.cmej.org.za Why should you care? You are about to leave your
More informationHybrid Muscular VSD Closure in Small Weight Children
Hybrid Muscular VSD Closure in Small Weight Children Shakeel A Qureshi, on behalf of: John P. Cheatham, MD George H. Dunlap Endowed Chair in Interventional Cardiology Director Cardiac Catheterization &
More informationIndex. Note: Page numbers of article titles are in boldface type.
Index Note: Page numbers of article titles are in boldface type. A Acetate, in pediatric surgical patients, 525 526 Acute respiratory distress syndrome (ARDS), immune-modulating nutrition in, 584 585 Aerobic
More informationPleural fluid. creatinine - urinothorax haematocrit -haemothorax bilirubin gut perforation. Fluid samples 1st Plain Universal ( cell count)
Examination Purpose of test Sample 17725 Fluid Profile (appearance, culture, WBC differential, ph, total protein, glucose, amylase, triglyceride, albumin, HDL) Peritoneal/ascitic and pleural fluid are
More informationPaediatrica Indonesiana
Paediatrica Indonesiana VOLUME 53 July NUMBER 4 Original Article Transcatheter vs. surgical closure of patent ductus arteriosus: outcomes and cost analysis Mulyadi M Djer, Mochammading, Mardjanis Said
More informationIntroduction to Clinical Nutrition
M-III Introduction to Clinical Nutrition Donald F. Kirby, MD Chief, Section of Nutrition Division of Gastroenterology 1 Things We Take for Granted Air to Breathe Death Taxes Another Admission Our Next
More informationWales Neonatal Network Guideline
Guideline for the management of a baby with a stoma Types of Stomata: 1. End stoma without mucus fistula The proximal bowel end is brought out through the abdominal wall as a stoma and the distal end is
More informationNICU Nutrition Pathway
NICU Nutrition Pathway Safely Infusing NICU TPN Starter and Custom TPN April17 th 2018 Pharmacists: Paul Kasprzak RPH BCPS Kelly Kopec PharmD Major Practice Changes in the Preparation and Administration
More informationMultiphasic Blood Analysis
Understanding Your Multiphasic Blood Analysis Test Results Mon General thanks you for participating in the multiphasic blood analysis. This test can be an early warning of health problems, including coronary
More informationAdult Congenital Heart Disease
Adult Congenital Heart Disease They re out there and coming to find you. Clare O Donnell Paediatric and Adult Congenital Cardiologist Green Lane Paediatric and Congenital Cardiac Service Congenital Heart
More informationOUTCOMES & CARE REPORT. The Heart Center. at Primary Children s Hospital
2015 OUTCOMES & CARE REPORT The Heart Center at Primary Children s Hospital Overview of Heart Surgery Beating National Benchmarks The Society of Thoracic Surgeons (STS) is a national non-profit organization
More information10/3/2012. Pediatric Parenteral Nutrition A Comprehensive Review
Critical Care Nutrition Foundation for Moving Forward Justine Turner MD PhD Department of Pediatric Gastroenterology and Nutrition University of Alberta I have the following financial relationships to
More informationMinimal Enteral Nutrition
Abstract Minimal Enteral Nutrition Although parenteral nutrition has been used widely in the management of sick very low birth weight infants, a smooth transition to the enteral route is most desirable.
More informationUnderstanding your child s heart. Tricuspid atresia
Understanding your child s heart Tricuspid atresia 9 bout this book Contents If you re reading this book, you ve probably just had some very upsetting news and have lots of questions running through your
More informationGlenn and Fontan Caths:
Glenn and Fontan Caths: Pre-operative evaluation and Trouble-shooting Cavo-Pulmonary Shunts Daniel H. Gruenstein, M.D. Director, Pediatric Interventional Cardiology University of Minnesota Children s Hospital,
More informationMCT AND THE ROLES NUTRITION
MCT AND THE ROLES NUTRITION Nguyen Hoang Nhut Hoa Department of Nutrition Children's Hospital 2 OBJECTIVES Structure Absorption and metabolic Effects of MCT in the treatment of certain diseases Demand
More informationPersistent chylothorax in the pediatric patient, regardless
Treatment of Refractory Chylothorax With Externalized Pleuroperitoneal Shunts in Children Andrew B. Wolff, BA, Mark L. Silen, MD, Evan R. Kokoska, MD, and Bradley M. Rodgers, MD Department of Surgery,
More informationThe Case Begins. The case continued. Necrotizing Enterocolitis
Bugs, Drugs and Things that go Bump in the Night From ghoulies to ghosties and long leggety beasties & things that go bump in the night, good lord deliver us Old Cornish Prayer Caring for premature infant
More informationCOLORECTAL RESECTIONS
COLORECTAL RESECTIONS What is a colorectal (bowel) resection? Surgery to remove a part of the large bowel is called a resection. Different parts of the colon require different operations and have different
More informationPROTOCOL FOR PARENTERAL NUTRITION
PROTOCOL FOR PARENTERAL NUTRITION Based on; Roberton s textbook of neonatology. 4 th edition. 2005. Sudha Chaudari and Sandeep Kumar.TPN in neonates. Indian Paediatrics. November 2006 Deepak Chawla, Anu
More informationFoetal Cardiology: How to predict perinatal problems. Prof. I.Witters Prof.M.Gewillig UZ Leuven
Foetal Cardiology: How to predict perinatal problems Prof. I.Witters Prof.M.Gewillig UZ Leuven Cardiopathies Incidence : 8-12 / 1000 births ( 1% ) Most frequent - Ventricle Septum Defect 20% - Atrium Septum
More informationChildren s of Alabama. Birmingham, Alabama
Preoperative Evaluation of Pediatric Patients Heather Rankin, CRNA, MSN Children s of Alabama Birmingham, Alabama Objectives Define NPO guidelines Review history assessment Review system assessment Review
More information37 2 Blood and the Lymphatic System
37 2 Blood and the Lymphatic System 1 Blood Blood is a connective tissue that contains both dissolved substances and specialized cells. The functions of blood include: collecting oxygen from the lungs,
More informationDynamic MR Lymphangiography
Dynamic MR Lymphangiography Rajesh Krishnamurthy, MD EB Singleton Department of Radiology, Texas Children s Hospital, Baylor College of Medicine, Houston, TX Acknowledgement: Dr. Sheena Pimpalwar, MD Interventional
More informationNEC. cathy e. shin childrens hospital los angeles department of surgery university of southern california keck school of medicine
NEC cathy e. shin childrens hospital los angeles department of surgery university of southern california keck school of medicine Necrotizing enterocolitis (NEC) the most common and most lethal disease
More information