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 with chyle leaks and can range from primary treatment to adjunctive therapy The best route for nutrition, the optimal mix of nutrients, and the required duration of the therapy are unclear Our study review the options for a nutritional care plan and provide practical tips for implementing and monitoring such a plan
Various nutritional strategies were applied in the management of Chylothorax in the cardiothoracic intensive care unit of our centre Exclusive Medium Chain Triglyceride (MCT) feeds (90 % and 60 %) MCT feeds( 90% and 60%) with fat free diet
NUTRITIONAL INFORMATION Per 100 gms 90% MCT 60% MCT Energy (Kcal) 424 464 Protein equivalent g 11.4 13 Carbohydrates g 68 64.9 Fat g 11.8 16.9 Saturated Fats g 10.3 12.2 Monounsaturated g 0.35 1.7 Polyunsaturated g 0.6 2.2 Osmolarity mosm 250 315
METHOD Patients who had chyle leak after cardiac surgery were included 13 subjects were included in this study Various parameters Anthropometry Biochemical Chyle leak volume Post Operative Day -Chyle detected and stopped Diet plan were analysed until progress towards resolution
RESULTS DISTRIBUTION BASED ON SEX DISTRIBUTION BASED ON AGE 5 8 2 2 < 6 months 1-2 yrs 9 10-11 yrs Males Females 9 of 13 were below 6 months of age
RESULTS DISTRIBUTION BASED ON DIAGNOSIS 10 10 9 8 7 6 5 4 3 2 1 0 Cyanotic Heart disease 3 Acyanotic Heart disease Cyanotic Heart disease Acyanotic Heart disease Chyle leak was predominant in Cyanotic heart disease subjects than Acyanotic heart disease subjects
NUTRITION ASSESSMENT 9 8 7 DISTRIBUTION BASED ON NUTRITIONAL STATUS 8 6 5 4 5 3 2 1 0 Wasting Wasting &Stunting
DISTRIBUTION BASED ON THE DIETS 2 7 2 90% MCT feeds 90% MCT feeds + fat free diet 2 60% MCT feeds 60% MCT feeds + fat free diet 5 month <6 month : 5 on 60% MCT Feeds+ FF Diet < 5months 2 on 90 % MCT Feeds 2 on 60% MCT Feeds
NUTRITIONAL REQUIREMENT Estimated by catch up Growth formula Calorie needs DRI for energy x Ideal wt for ht (kg) Actual wt (kg) Protein needs DRI Protein for age x Ideal wt for ht (kg) Actual wt (kg) DRI Dietary Reference Intake Ref:- Manual of Pediatric Nutrition by Hendricks & Duggan
NUTRIENT REQUIREMENTS 100 98 98.5 Percentage of calories met 96 94 94 92 90 88 86 87 88 84 82 80 90% MCT FEEDS 90% MCT FEEDS+DIET 60% MCT FEEDS 60% MCT FEEDS + DIET Feed Osmolarity 250 mosm (90%), 315 mosm (60%)
gm / kg NUTRIENT REQUIREMENTS 3 PROTEIN REQUIREMENT MET 2.5 2 1.5 1 2 2.5 1.65 1.75 0.5 0 90% MCT Feeds 90% MCT Feeds + Diet 60% MCT Feeds 60% MCT Feeds + Diet
ON OCTREOTIDE 10 10.25 8 6 4 3 4.4 90% MCT feeds 60% MCT feeds 2 2 1 1.12 0 No. of patients Dosage (mg / kg/day) No. of days
MEAN VOLUME OF CHYLE 180 170.7 160 140 120 100 80 124.5 115 138 145 135 Mean volume of Chyle (ml) without Octreotide 60 40 Mean volume of Chyle (ml) with Octreotide 20 0 90 % MCT feeds 90% MCT feeds + Fat free diet 60% MCT feeds 60% MCT feeds +Fat free diet
MEAN DAY CHYLE STOPPED 14 12 10 6 8 5 Mean day chyle leak stopped with Octreotide 6 10 Mean day chyle leak stopped without Octreotide 4 5.7 7.5 7 2 0 90 % MCT feeds 90% MCT feeds + Fat free diet 60% MCT feeds 60% MCT feeds +Fat free diet
COMPARISON BETWEEN 90% & 60% MCT FEEDS Duration of Drainage Max loss of Chyle 6 6 5.5 5 4.5 5 90% MCT feeds 60% MCT feeds 112 110 108 106 104 102 100 98 96 94 100 110.5 90% MCT feeds 60% MCT feeds
COMPARISON BETWEEN 90% & 60% MCT FEEDS AND DIET Duration of Drainage Max loss of Chyle 170 165 160 8 5 90% MCT feeds + fat free diet 60% MCT feeds + fat free diet 155 150 145 140 145 170 135 130 90% MCT feeds + fat free diet 60% MCT feeds + fat free diet
COMPARISON OF THE DAY CHYLE STOPPED 8 POD chyle stopped 8 POD chyle stopped 8 7.5 7 6 7 7 5 4 3 2 4 8 6.5 90% MCT feeds 60% MCT feeds 1 0 90% MCT feeds + fat free diet 60% MCT feeds + fat free diet
CASE STUDY 4 months old boy, was presented with complaints of moist cough since 2 days. History of Suck rest suck cycle and excessive sweating of forehead were noticed before one month and had frequent respiratory tract infection. Diagnosis : Ventricular Septal defect (VSD) Surgery : VSD Closure
NUTRITION ASSESSMENT Anthropometric Measurement Admit weight - 4.42 Kg Admit height - 57 cm Wasting-severe Stunting-moderate Nutrition related diagnosis-severe Malnutrition Diet History Had been on direct breast milk and had interrupted feedings (suck- rest -suck cycle)
DIET IN HOSPITAL POST OPERATIV E DAY FEEDING ROUTE DIET PRESCRIBE D CALORIES (Kcals) PROTEIN (gm) TGL (mg/dl) Day 1 By was on CHEST OPEN - TPN Initiated Central line TPN @ 10ml/hr 205 4.4 170 Day 2 Central line TPN @ 15ml/hr 298 9 Day 3 Central line TPN @ 18ml/hr 356 12
DIET IN HOSPITAL POST OPERA TIVE DAY FEEDING ROUTE DIET PRESCRI BED CALORI ES (Kcals) PROTEI N (gm) TGL (mg/dl ) CHYLE DRAINAGE (ml) Day 4 EN Initiated Day 4-5 NG Standard Infant milk formula @ 15ml/hr 267 6 110 Chyle leak was detected. Pleural fluid TGL 353 mg/dl
DIET IN HOSPITAL POST OPERATIVE DAY FEEDING ROUTE DIET PRESCRIBE D CALORIES (Kcals) PROTEIN (gm) CHYLE DRAINAGE (ml) Day 6-7 NG 60% MCT Feeds @ 15ml/hr Day 8 Oral 60% MCT Feeds@ 18ml/hr Chest drainage tube removed 292 8 45 365 10 30 Day 9 10 Oral 60% MCT Feeds @ 18ml /hr + MCT Oil 412 10 Day 11 Discharged on oral feeds
DISCHARGE DIET EDUCATION Discharge Diet 450 k cal, 10 gm protein diet 60 % MCT feed with MCT Oil On Follow up 2 nd Review (After 2months) Weight : 5.7 Kg Advised on Weaning diet with MCT oil
CONCLUSION MCT is a vital adjunct for the treatment of Chylothorax in post operative cardiac patients. Ideally a 90% MCT seem to resolve the condition faster than lesser concentration (60% MCT) Due to non-availability in India / cost constrain of importing 90% MCT feed, 60% MCT can be used as it has a significant impact in the course of the illness