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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
8
5
DISTRIBUTION BASED ON SEX
Males
Females
9
2
2
DISTRIBUTION BASED ON AGE
< 6 months
1 - 2 yrs
10 - 11 yrs
9 of 13 were below 6 months of age
RESULTS
0
1
2
3
4
5
6
7
8
9
10
Cyanotic Heart disease Acyanotic Heart disease
10
3
DISTRIBUTION BASED ON DIAGNOSIS
Cyanotic Heart disease
Acyanotic Heart disease
Chyle leak was predominant in Cyanotic heart disease subjects
than Acyanotic heart disease subjects
NUTRITION ASSESSMENT
8
5
0
1
2
3
4
5
6
7
8
9
Wasting Wasting &Stunting
DISTRIBUTION BASED ON NUTRITIONAL STATUS
2
2
2
7
DISTRIBUTION BASED ON THE DIETS
90% MCT feeds
90% MCT feeds + fat free diet
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
98.5
94
87
88
80
82
84
86
88
90
92
94
96
98
100
90% MCT FEEDS 90% MCT FEEDS+DIET 60% MCT FEEDS 60% MCT FEEDS + DIET
Percentage of calories met
Feed Osmolarity – 250 mOsm (90%) , 315 mOsm (60%)
NUTRIENT REQUIREMENTS
2
2.5
1.65 1.75
0
0.5
1
1.5
2
2.5
3
90% MCT Feeds 90% MCT Feeds + Diet 60% MCT Feeds 60% MCT Feeds + Diet
gm
/ k
g
PROTEIN REQUIREMENT MET
ON OCTREOTIDE
0
2
4
6
8
10
No. of patients Dosage (mg / kg/day)
No. of days
1
4.4
1.12
3
10.25
2
90% MCT feeds
60% MCT feeds
MEAN VOLUME OF CHYLE
0
20
40
60
80
100
120
140
160
180
90 % MCT feeds
90% MCT feeds + Fat free diet
60% MCT feeds 60% MCT feeds +Fat free diet
124.5
138 145
170.7
115
135
Mean volume of Chyle (ml) without Octreotide
Mean volume of Chyle (ml) with Octreotide
MEAN DAY CHYLE STOPPED
0
2
4
6
8
10
12
14
90 % MCT feeds
90% MCT feeds + Fat
free diet
60% MCT feeds
60% MCT feeds +Fat
free diet
5.7
7.5 7
10
5
6
Mean day chyle leak stopped with Octreotide
Mean day chyle leak stopped without Octreotide
COMPARISON BETWEEN 90% &
60% MCT FEEDS
4.5
5
5.5
6
90% MCT feeds 60% MCT feeds
5
6
Duration of Drainage
94
96
98
100
102
104
106
108
110
112
90% MCT feeds 60% MCT feeds
100
110.5
Max loss of Chyle
COMPARISON BETWEEN 90% &
60% MCT FEEDS AND DIET
5
8
Duration of Drainage
90% MCT feeds + fat free diet
60% MCT feeds + fat free diet
130
135
140
145
150
155
160
165
170
90% MCT feeds + fat free diet
60% MCT feeds + fat free diet
145
170
Max loss of Chyle
COMPARISON OF THE DAY
CHYLE STOPPED
0
1
2
3
4
5
6
7
8
90% MCT feeds + fat free diet
60% MCT feeds + fat free diet
4
8
POD chyle stopped
6.5
7
7.5
8
90% MCT feeds 60% MCT feeds
7
8
POD chyle stopped
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
292 8 45
Day 8 Oral 60% MCT
Feeds@
18ml/hr
365 10 30
Chest drainage tube removed
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 – 2nd 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
