Development of consensus recommendations for the management of post-operative chylothorax in paediatric CHD

Abstract

Objective: A standardised multi-site approach to manage paediatric post-operative chylothorax does not exist and leads to unnecessary practice variation. The Chylothorax Work Group utilised the Pediatric Critical Care Consortium infrastructure to address this gap. Methods: Over 60 multi-disciplinary providers representing 22 centres convened virtually as a quality initiative to develop an algorithm to manage paediatric post-operative chylothorax. Agreement was objectively quantified for each recommendation in the algorithm by utilising an anonymous survey. “Consensus” was defined as ≥ 80% of responses as “agree” or “strongly agree” to a recommendation. In order to determine if the algorithm recommendations would be correctly interpreted in the clinical environment, we developed ex vivo simulations and surveyed patients who developed the algorithm and patients who did not. Results: The algorithm is intended for all children (<18 years of age) within 30 days of cardiac surgery. It contains rationale for 11 central chylothorax management recommendations; diagnostic criteria and evaluation, trial of fat-modified diet, stratification by volume of daily output, timing of first-line medical therapy for “low” and “high” volume patients, and timing and duration of fat-modified diet. All recommendations achieved “consensus” (agreement >80%) by the workgroup (range 81–100%). Ex vivo simulations demonstrated good understanding by developers (range 94–100%) and non-developers (73%–100%). Conclusions: The quality improvement effort represents the first multi-site algorithm for the management of paediatric post-operative chylothorax. The algorithm includes transparent and objective measures of agreement and understanding. Agreement to the algorithm recommendations was >80%, and overall understanding was 94%.

Nutrition for critically ill children with congenital heart disease

“…Importantly, the authors acknowledge the lack of robust research in this area and specify that the guidelines are intended to standardize practice to allow for further research and subsequent development of evidence-based best practice guidelines. 125 The PC 4 guidelines also provide general recommendations for diet modifications, including defatted human milk, medium-chain triglyceride (MCT) formulas, and oral fat-modified diet. 125 MCT formulas are used in chylothorax treatment because MCTs are absorbed directly into the bloodstream, bypassing the lymphatic system.…”

“…[128][129][130][131][132] It is important to note that infants receiving defatted human milk require fat-soluble vitamin supplementation and the use of certain MCT formulas requires additional trace element supplementation. 125 In children and adolescents, there is not consensus on the degree of fat restriction in a fatmodified diet, which can range from <10 g/day 133 to <30% of calories from fat per day. 134,135 Patients with chylothorax are at risk for significant nutrition morbidity, including malnutrition, fat-soluble vitamin deficiencies, trace mineral deficiencies, and essential fatty-acid deficiency (EFAD).…”

“…There is a lack of consensus regarding the appropriate duration of nonoral status time, as well as the duration of a fat‐modified diet. The first multicenter algorithm for the management of pediatric postoperative chylothorax was published in 2022 by the PC 4 Chylothorax Work Group, with recommendations based on current literature and expert consensus 125 . As multiple studies have shown resolution of chylothorax in 38%–61% of patients with a fat‐modified diet alone, 126,127 the guidelines recommend that all patients able to tolerate feeds trial a fat‐modified diet for 24–72 h, followed by stratification to high‐ or low‐volume chest tube output (>20 or ≤20 ml/kg/day).…”

“…For those with ≤10 ml/kg/day output on a fat‐modified diet, it should be continued for 2–4 weeks. Importantly, the authors acknowledge the lack of robust research in this area and specify that the guidelines are intended to standardize practice to allow for further research and subsequent development of evidence‐based best practice guidelines 125 …”

“…Defatted human milk, which must be fortified to provide adequate calorie intake, has been proven to be a safe and effective alternative to MCT formulas while also providing the known benefits of human milk 128–132 . It is important to note that infants receiving defatted human milk require fat‐soluble vitamin supplementation and the use of certain MCT formulas requires additional trace element supplementation 125 . In children and adolescents, there is not consensus on the degree of fat restriction in a fat‐modified diet, which can range from <10 g/day 133 to <30% of calories from fat per day 134,135 …”