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The Chyle Leak Nutritional Implications, Management, and a Nutrition Care Case Study

The Chyle Leak Nutritional Implications, Management, and a Nutrition Care Case Study. Erin Lastnik Dietetic Intern Sodexo Mid-Atlantic Dietetic Internship February 1, 2013. Objectives. Identify two nutritional implications of a chyle leak.

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The Chyle Leak Nutritional Implications, Management, and a Nutrition Care Case Study

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  1. The Chyle LeakNutritional Implications,Management, and a Nutrition Care Case Study Erin Lastnik Dietetic Intern Sodexo Mid-Atlantic Dietetic Internship February 1, 2013

  2. Objectives • Identify two nutritional implications of a chyle leak. • Explain the role of chyle in fat absorption. • Identify three nutritional interventions for a chyle leak.

  3. Introduction • IH is a 62 year old female • African American • Graduated high school, married with six children, retired • Admitted to St. Joseph’s on 11/24/12

  4. Medical Background • Past Medical History • Type 2 diabetes, CVA x2, CAD s/p CABG x4, HTN, anemia, CKD Stage 3, one C-section, hysterectomy • CABG x4 was at St. Joseph’s on 10/29/12 • Rehabilitation center for three weeks • Left pleural effusion • Three admissions for thoracentesis

  5. Admission 11/24/12 • IH admitted with SOB, chest discomfort • Dx: Pleural Effusion • Physical • Reduced muscle strength, slow speech, trace edema • Medications PTA • Aspirin, Colace, Doxycycline, Levemir, Lexapro, Plavix, Simvastatin, Toprol XL, Oxycodone, Reglan • Labs WNL • Albumin 2.6 g/dL; Creatinine 1.2 mg/dL

  6. Initial Findings • Chest x-ray and thoracentesis with fluid analysis • Bilateral chylothorax

  7. Definitions • Chyle • White, milky fluid containing triglycerides, protein, lymphocytes and electrolytes • Chylothorax • Collection of chyle and lymphatic fuid in the pleural cavity

  8. Anatomy and Digestion • Thoracic duct • Cysternachyli • Long-chain Triglycerides (LCT) • Enzymes • Micelle  Re-esterification  Chylomicron • Short chain/Medium chain Triglycerides (SCT/MCT) • No micelle or chylomicron • Mucosa  Portal vein • Evidence in lymphatic system

  9. Etiology and Pathology • Primary Etiologies • Congenital, obstruction, lymphagiectasis • Secondary • Head/neck, thoracic, pancreatic, esophagus sx • Hours to months before identified • Chylothorax, chylous ascites, chylopericardium • Dx • TG >100 mg/dL • TG 50-100 mg/dL requires chylomicrons

  10. Nutritional Implications • Hypovolemia • Hypokalemia, hyponatremia, hypocalcemia • Protein loss • Hypoalbuminemia • Malabsorption • Caloric, vitamins, medications • Immunosuppression

  11. Management of a Chyle Leak

  12. Conservative Interventions • Very low fat diet • <10 - <20 g/day • Caloric loss of fat: MCT oil/elemental formula • MCT oil does NOT prevent EFAD • Enteral Nutrition (EN) • Elemental/Semi-elemental formula • Peptamen® • Total Parenteral Nutrition (TPN) • Chyle flow • Bowel rest • Bowel atrophy/infection

  13. Surgical Interventions • Persistent leaks: >500 mL/day for two weeks • Thoracic duct ligation • Thoracic duct embolization • Fibrin glue

  14. Treatment and Hospital Course

  15. Initial Visit 11/26/12: Assessment • Thoracentesis • Poor appetite PTA • Felt it was increasing • “Picky eater” • Nausea • Reported weight loss • Unsure of how much • ~10# per computer records • Labs: BUN, Creatinine, Glucose • Estimated needs • 1425 – 1600 kcal (25 – 28 kcal) • 57 – 74 g protein (1 – 1.3 g/kg)

  16. Initial Visit: Diagnosis • Suspected Suboptimal PO intake R/T Poor appetite and nausea AEB pt consuming 0 – 25% per computer records

  17. Initial Visit: Interventions • Meals and Snacks • Recommend continue current diet (Moderate Consistent CHO), consider liberalizing to Regular if PO intake <50% • Medical Food Supplement • Recommend Resource Health Shake SF TID with meals (600 kcal, 24 g protein) • Goal: PO intake >50%

  18. Initial Visit: Monitor/Evaluate • PO intake • Labs • GI Status • Weight

  19. Follow-up 11/29/12: Assessment • Fluid analysis revealed bilateral chylothorax • Bilateral pigtail catheters • OR 12/3/12 • Thorascopic decortication with bronchoscopy • “Zero Fat” diet with Health Shakes • Grand-daughter present during interview to confirm poor PO intake • Estimated needs • 1425 – 1600 kcal (25 – 28 kcal) • 74 – 103 g protein (1.3 – 1.8 g/kg)

  20. First Follow up: Diagnosis • Suspected Suboptimal PO intake – ongoing • Suspected Suboptimal PO intake – confirmed • Inadequate Oral Intake R/T Nausea and decreased appetite AEB 0% of meals per computer records and family member • Altered GI Function R/T Change in accessory organ function AEB Fluid analysis revealed chyle leak

  21. First Follow-up: Interventions • Meals and Snacks • Recommend 20 g Low Fat diet • Medical Food Supplement • Recommend change supplement to Resource Breeze TID due to zero-fat content (750 kcal, 27 g protein) • Enteral Nutrition (EN) • Recommend Vital AF 1.2 @ 55 mL/hr (1584 kcal, 99 g protein) • Parenteral Nutrition (PN) • Recommend Standard PPN (1540 kcal, 100 g CHO, 100 g protein, 80 g lipid)

  22. First Follow-up: Monitor/Evaluate • Plan of care • PO Intake • GI Status • Weight • I&Os

  23. Second Follow-up 11/30/12: Assessment • PPN initiated night of 11/29/12 • Central line plan • Remained on “Zero Fat” diet • PO intake was still 0% • Resource Breeze ordered

  24. Second Follow-up: Diagnosis • Suboptimal Oral Intake – ongoing

  25. Second Follow-up: Interventions • PN • If TPN initiated, recommend initiate at • Amino Acids 15% 550 mL= 75 g protein • Dextrose 70% 250 mL = 175 g dextrose • Lipid 20% 200 mL = 20 g lipid • Provides 1295 kcal • Replete electrolytes PRN, pt is a refeeding syndrome risk • Meals and Snacks • Recommend continue “Zero Fat” diet per MD

  26. Second Follow-up: Monitor/Evaluate • PO intake • Labs • GI Status • Weight • Plan of care

  27. Follow-ups: 12/1, 12/4, 12/5, 12/7, 12/10, 12/13 • PPN 11/29 • K+ drop 4.1 – 3.8 • TPN 12/4 (POD #1) • K+ drop 3.8 – 3.6 • NPO post TPN initiation • Elevated BG levels • 10 units insulin in TPN bag; 50 units Lantus • Prealbumin: 11 mg/dL • Triglycerides: 64 mg/dL • Hypocalcemia • 8.7, 8.4, 8.2, 8, 7.8 mg/dL

  28. Follow-ups 12/1 – 12/13 Continued • Recommendations • Increase Amino Acids to 570 mL = 85 g • Increase Amino Acids to 600 mL = 90 g (taken) • Routine chest scans • Decreased chyle accumulation • Chylopericardium • OR 12/12 • Pericardiocentesis with pericardial drain • PleurX catheter

  29. Follow-ups 12/15, 12/18, 12/19 • Decreased drainage output; leak resolved? • TPN stopped • Regular diet ordered • Bilateral pigtails removed • Calorie Count • 0%; 1 meal = 275 kcal, 11 g protein • IH not meeting needs • Recommendation for Glucerna 1.2 @ 55 mL/hr (1584 kcal, 79 g protein) • Recommend reinitiate TPN at previous rate

  30. Follow-ups 12/20, 12/21, 12/24, 12/28 • IH began to eat and had increased drainage • TPN recommended to PA • TPN reinitiated on 12/21 with previous formula • TPN x3 weeks • NPO • Prealbumin: 13 mg/dL; 16 mg/dL • Triglycerides: 141 mg/dL • BG >200 mg/dL • 20  45  65 units of insulin in TPN bage

  31. Discharge • IH discharged on 1/2/13 • Dx: Chylothorax • TPN x3 weeks • NPO • PleurX catheter • Pericardial drain removed

  32. Questions?

  33. References • Bonner GM, Warren JM. A Review of the Nutritional Management of Chyle Leakage in Adults. Journal of Human Nutrition and Dietetics. 1998 (11) 105-114. • Fahimi H, Casselman FP, Mariani MA, van Boven WJ, Knaepen PJ, van Swieten HA. Current Management of Postoperative Chylothorax. Ann ThoracSurg 2001;71:448-450. • Gottschlich MM. The Science and Practice of Nutrition Support: A Case-Based Core Curriculum. Dubuque, IA: Kendall Hunt Pub Co; 2000; 481 – 485. • Hakim NS, Papalois VE. Surgical Complications: Diagnosis and Treatment. London, England: Imperial College Press; 2007; 222 – 225. • Maldonado F, Hawkins FJ, Daniels CE, Doerr CH, Decker PA, Ryu JH. Pleural Fluid Characteristics of Chylothorax. Mayo Clin Proc. 2009;84:129–133. • McCray S, Parrish CR. When Chyle Leaks: Nutrition Intervention. Practical Gastroenterology 2011; 94; 12 – 22. • McGrath EE, Blades Z, Anderson PB. Department of Respiratory Medicine, Northern General Hospital, UK. Chylothorax: Aetiology, Diagnosis and Therapeutic Options. http://www.pneumonologia.gr/articlefiles/chylothorax.pdf. Accessed 16 January 2013. • Nyquist GG, Hagr A, Sobol SE, Hier MP, Black MJ. Octreotide in the Medical Management of Chyle Fistula. Otolaryngology–Head and Neck Surgery; 128, 6; 910 – 911. • Pakula AM, Phillips W, Skinner RA. A Case of a Traumatic Chyle Leak Following an Acute Thoracic Spine Injury: Successful Resolution with Strict Dietary Manipulation. World Journal of Emergency Surgery 2011, 6:10. • Scholz GA, SirbuH, Semrau S, Anders K,  Mackensen A, SpriewaldBM. Persisting Right-sided Chylothorax in a Patient with Chronic Lymphocytic Leukemia: A Case Report. J Med Case Reports. 2011; 5: 492. • Skouras V, KalomenidisI. Chylothorax: Diagnostic Approach. CurrOpinPulmMed.2010 Jul;16(4):387-93. • Smoke A, DeLegge MH. Chyle Leaks: Consensus on Management?. NutrClinPract. 2008; 23 (5): 529-532 • Talwar A. Division of Pulmonary & Critical care medicine North-Shore University Hospital, Manhasset, NY. Chylothorax: Recent Advances.http://lungtherapeutics.com/appDocs/Chylothorax-web%20site.pdf. Accessed 17 January 2013. • Timoney M. Department of Surgery SUNY Downstate/Kings County Hospital Center. Management of Chylothorax. http://www.downstatesurgery.org/files/cases/Cyhlothorax.pdf. Accessed 16 January 2013. • Wakefield SC. ESPEN Congress. Specialized Oral or Enteral Nutrition Measures in Patients with Chyle Leaks. http://www.espen.org/presfile/Wakefield_2012.pdf. Accessed 17 January 2013.

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