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NUTRITIONAL MANAGEMENT
OF CHYLOTHORAX
Lekha.V.S
HOD- Department Of Dietetics
Apollo Children's Hospitals &
Apollo Women's Hospitals
Chennai, India
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INTRODUCTION
• Nutrition therapy plays a major role in
the conservative treatment of chyle leaks.
• Loss of this protein-rich, calorie-rich fluid can
cause complications including dehydration,
malnutrition and immuno suppression.
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CASE SCENARIO 9 month male child who is a K/C/O CHD – large VSD + PDA
H/o birth asphyxia, brief neonatal ventilation & persitant
stridor
Clinical history
Cyanosis : Nil
Clubbing : Nil
Icterus : Nil
Temperature : 102°F
Pulse :106/min
BP: 98/48mm Hg
CVS: S1,S2 Present ,systolic murmer present
Surgery : VSD + PDA Division
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NUTRITIONAL ASSESSMENT
Anthropometry
Admission weight : 7.2 Kg
Admission height : 72.2cm
Head circumference : 40 cm
% Weight for height : 78 %
Wasting (Mild)
% Height for age : 99%
BMI for age percentile : <3rd percentile
Diet history : DBM + Weaning diet
Nutrition related diagnosis- Acute Malnutrition
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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
Required Calories : 736 k.cal
Required Protein : 15 gm
Ref:- Manual of Pediatric Nutrition by Hendricks & Duggan
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POST OPERATIVE DIET
POD FEEDING
ROUTE
DIET
PRESCRIBED
CALORIES
(Kcals)
PROTEIN
(gm)
FAT ( gm)
Day 1 NBM
Day 2 - 3 Central line TPN @
12ml/hr
581 7 7
Day 4 -5 Central line TPN @
15ml/hr
758 14 10
Day 6 PN + NG
Total
TPN @ 10
ml/hr
494 7 7
RTF@15ml/hr 266
760
8
15
11
18
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POST OPERATIVE DIET
POD FEEDING ROUTE DIET
PRESCRIBED
CALORIES
(Kcals)
PROTEIN
(gm)
FAT ( gm)
Day 7 NG RTF@ 24ml/hr 425 14 18
Day 8
Chyle leak was detected. Pleural fluid TGL – 363 mg/dl
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Medical Nutrition Therapy
Focuses on restriction of dietary long-chain
triglycerides while correcting other nutrient
deficiencies
Goals
• Decrease production of chyle fluid
• Replace fluid and electrolytes
• Maintain or replete nutritional status and
prevent malnutrition
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POST OPERATIVE DIET POD FEEDING ROUTE DIET
PRESCRIBED
CALORIES (Kcals) PROTEIN
(gm)
Day 8 NG RTF @ 24ml/hr
90 % MCT
449 9.6
Day 9-10 NG RTF @ 30 ml/hr
90% MCT
509 12
Day 11 ORAL MCT Based Liquid
diet
484 10
Chyle leak resolved Chest drainage tube removed
Day 12 -
13
Oral MCT Based
semisolid diet
580 12
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DISCHARGE DIET Day 14- Discharge
Diet : MCT Based semisolid
diet
Calorie -100kcal / kg
Protein - 2gm/kg day
Review after 1 week
Weight : 7.5 kg
Diet advised : Semisoild Diet
On follow up (After 2 months)
Weight : 9.3 Kg
Height : 73 cm
Nutritional status :
Well nourished
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Incorporating MCT into the
Diet : A CHALLENGE
• Sip or eat slowly
• Start with small volume. Taken as small “shots”
• Flavourings can be added.
• Add to a fat free beverage of choice.
• Consider diluting with equal volume of water or
other fat free hot cereals, mashed potatoes,
vegetables , applesauce etc
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Things to remember
• Virtually impossible to remove all fat from the diet. Many
fruits, vegetables and even “fat free” products contain
traces of fat .
• Coconut oil and MCT are not the same, as only 66% of
coconut oil is MCT—the rest is long chain fat
• MCT is available as MCT oil and contain 100ml -780kcal
• Fat-soluble vitamins and EFA may need to be
supplemented.
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NUTRITIONAL MANAGEMENT OF
CHYLOTHORAX IN CARDIO THORACIC
INTENSIVE CARE UNIT
UNPUBLISHED DATA
Ms. V Lekha 1 , Dr. R Nataraj2
Clinical Dietetics1, Critical care2
Apollo Children’s Hospitals,
Chennai
India
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OBJECTIVE :
Our observational study attempts to reveal the best options for the
nutritional care plan for chyle leak .
METHODOLOGY
Patients who had chyle leak after cardiac surgery were included
Parameters Includes -
Anthropometry
Biochemical
Chyle leak volume
Post Operative Day -Chyle detected and stopped
Diet plan were analysed until progress towards resolution
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NUTRITIONAL INTERVENTIONS
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
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RESULTS
13
10
DISTRIBUTION BASED ON SEX
Males
Females
9
5
2
5
2
DISTRIBUTION BASED ON AGE
< 6 months
6 months- 1 year
1-3 years
4-6 years
10-12 years
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DISTRIBUTION BASED ON
DIAGNOSIS
Chyle leak was predominant in Cyanotic heart disease subjects
than Acyanotic heart disease subjects
0
2
4
6
8
10
12
14
16
Cyanotic Heart disease Acyanotic Heart disease
15
8 Cyanotic Heart disease
Acyanotic Heart disease
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NUTRITION ASSESSMENT
0
2
4
6
8
10
12
14
Wasting Wasting & Stunting
13
10
Distribution based on Nutritional status
Wasting
Wasting & Stunting
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Composition of MCT products
NUTRITIONAL
INFORMATION
(per 100gms)
90 %
MCT
FEED
70%
MCT
68%
MCT
FEED
60%
MCT FEED
(NOT AVAILABLE)
48%
MCT
Energy (Kcals) 424 475 465 464 463
Protein (gms) 11.4 14.25 17.5 13 12.9
Fat (gms) 11.8 18.5 17.4 16.9 16.5
Osmolality
(mOsm/kg0
250 420 360 312 370
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Composition of MCT products
NUTRITIONAL
INFORMATION
(per 100gms)
90 %
MCT
FEED
70%
MCT
68%
MCT
FEED
60%
MCT
FEED
(NOT
AVAILAB
LE)
48%MCT
Energy (Kcals) 424 475 465 464 463
Protein (gms) 11.4 14.25 17.5 13 12.9
Fat (gms) 11.8 18.5 17.4 16.9 16.5
MCT 10.6 12.95 12.2 10.5 7.9
Osmolality
(mOsm/kg0
250 420 360 312 370
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5
6
4
8
0
1
2
3
4
5
6
7
8
9
90% MCT feeds 90% MCT feeds + fat free diet
60% MCT feeds 60% MCT feeds + fat free diet
DISTRIBUTION BASED ON DIETS
90% MCT feeds
90% MCT feeds + fat free diet
60% MCT feeds
60% MCT feeds + fat free diet
DIET DISTRIBUTION
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OCTREOTIDE
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
90% MCT 60% MCT 60% mct+ fat free diet
1
5
2
Number of patients with octeotride
90% MCT
60% MCT
60% mct+ fat free diet
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MEAN VOLUME OF CHYLE
0
50
100
150
200
250
300
350
90 % MCT feeds 90% MCT feeds + Fat free diet
60% MCT feeds 60% MCT feeds +Fat free diet
120 130 146
165
110
144
150
Mean volume of chyle
with octeotride
without octeotride
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COMPARISON BETWEEN 90% & 60%
MCT FEEDS
4.4
4.6
4.8
5
5.2
5.4
5.6
5.8
6
90% MCT feeds 60% MCT feeds
5
6
Duration of Drainage
5
8
90% MCT feeds + fat free diet
60% MCT feeds + fat free diet
0
1
2
3
4
5
6
7
8
9
Duration of Drainage
90% MCT feeds + fat free diet
60% MCT feeds + fat free diet
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COMPARISON OF THE DAY
CHYLE STOPPED
5
5.8
6.75
7.1
0
1
2
3
4
5
6
7
8
90 % MCT 90 % MCT + Fat free 60 % MCT 60 % MCT + Fat free
Comparing the duration of chyle leak between 90 % MCT and 60 % MCT feeds
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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 -
70% MCT can be used as it has a significant
impact in the course of the illness
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THANK YOU