Note: This guideline is currently under review. Show
Aim Definition of terms Complications Diagnosis and Assessment Management Special Considerations Chylothorax on Butterfly Ward Companion Documents References Evidence Table IntroductionChylothorax 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). AimTo guide the detection of chylothorax as well promote its management in a safe and effective manner amongst nursing
and medical staff. Definition of Terms
Complications Associated with ChylothoraxOngoing losses of chyle can result in:
Diagnosis and Assessment(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:
Management(See Figure 2)
Patient observationsIn 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. Special considerations
Chylothorax on Butterfly WardFor 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. Medical management on ButterflyIn terms of medical management, a trial of octreotide should be considered.
Ongoing management, special considerations and potential complications
Companion DocumentsLinks
References1. Australian Medicines Handbook (AMH). Available online from: https://childrens. amh.net.au/ monographs/octreotide 2. 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. Evidence TableChylothorax 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. What procedure was used to relieve the pleural effusion?One of the most common procedures to remove extra fluid is called thoracentesis. This involves using ultrasound to locate the fluid and a hollow needle to drain the fluid from the pleural space. Thoracentesis can improve breathing, reduce coughing and improve oxygen levels.
Which action should the nurse take to prepare a patient with a pleural effusion for a thoracentesis?The correct answer to today's NCLEX-RN® Question is...
Rationale: During a thoracentesis a needle is inserted into the intercostal space, so the nurse should assist the client to sit at the edge of the bed while leaning forward with their arms supported on a bedside table and a pillow or folded towel.
What is the prep for a thoracentesis?Before a thoracentesis, a chest ultrasound will be done to identify the exact location of the pleural effusion. An ultrasound is preferred because it is more accurate in determining the location of the effusion and the distance from the skin to the fluid collection than a chest X-ray or physical examination.
When preparing a patient for a thoracentesis The nurse positions the patient?3. Position the patient upright with their arms & head resting on a bedside table with a pillow. If the patient is unable to sit, they may be placed in a side-lying position on the edge of the bed on the unaffected side.
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