M. M. Winder1, D. K. Bailly3, R. J. Smout1, J. Marietta1, A. W. Eckhauser2 1Primary Childrens Hospital,Salt Lake City, UT, USA 2University Of Utah,Pediatric Cardiothoracic/Cardiothoracic Surgery/Surgery,Salt Lake City, UT, USA 3University Of Utah,Critical Care/Pediatrics,Salt Lake City, UT, USA
Introduction: Chylothorax following pediatric cardiac surgery occurs in 2.8% of patients nationwide and leads to significant morbidity. Currently no evidence-based protocol for the treatment of chylothorax exists, which leads to wide practice variation specifically in the timing of treatments and surgical interventions. Our primary goals were to decrease variability among providers treating pediatric patients with chylothorax following cardiac surgery by developing and implementing a management protocol and to decrease time to resolution of chylothorax as demonstrated by total days of chest tube utilization.
Methods: A chylothorax management protocol was implemented at Primary Children’s Hospital in July 2015. We included all patients aged 0-17y with chylothorac within 30 days of surgery. We excluded congenital chylothorax, Fontan patients, and those with chylothorax duration <24 hours. Retrospective analysis was completed on patients treated with chylothorax following cardiac surgery in a pre-protocol implementation cohort (July 2014 to June 2015, n = 19) and a post-protocol implementation cohort (July 2015 to March 2016, n = 13). Any patient with a diagnosis of chylothorax unrelated to cardiac surgery was excluded.
Results: Patient characteristics including age at time of surgery, sex, race, weight on admission, RACHS categories 1-3 and 4-6 and presence of genetic abnormalities were similar pre and post protocol implementation. Protocol compliance was 92%. Following protocol implementation, duration of chest tube used decreased from 12 days to 6.2 days (p = 0.04). Time to resolution of chylothorax decreased from a mean of 7.4 days to 4.1 days (p = 0.11), with a decrease in maximum time to resolution from 30 days to 9 days (see figure). Duration of medium chain triglyceride feeds decreased from 42 days to 30 days (p=0.03). Pre and post protocol duration of mechanical ventilation (4.7 days vs. 4.5 days; p = 0.91), hospital length of stay (13.1 days vs. 14.8 days; p = 0.73, and CICU length of stay (29 days vs. 21.8 days; p =0.33) were unchanged post protocol. There were no chest tube re-insertions, readmissions, or surgical interventions related to chylothorax in either the pre- or post-protocol cohorts.
Conclusion: Adoption of a chylothorax management protocol is feasible and in our small cohort of patients, implementation led to significantly improved duration of chest tube use and decrease from maximal time to resolution of chylothorax.
