Chylothorax
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Accumulation of chylous fluid in the pleural space.
Two main types
· as a result of a lymphatic malformation in the lungs: lymphangomatosis or lymphangiectases
· associated with a syndrome with lymphangiectases: Turner, Noonan, trisomy 21, Gorham-Stout, X-linked myotubular myopathy, yellow nail syndrome
· mutation of a9ß1 integrins
· cervicothoracic surgery with an injury of the thoracic duct
· cardiac surgery
· thrombosis of the superior vena cava (especially after the placement of a central venous catheter)
· Fontan surgical procedure
· injury of the left thoracic duct during the placement of a catheter into the subclavian vein
· tumor of the mediastinum
· mediastinal lymphadenopathy
· open or closed chest trauma
Diagnosis: milky pleural fluid (photo A), which divides into 3 layers after settling: an upper creamy layer that contains chylomicrons, an intermediate milky layer and a lower layer rich in cells. However, this milky aspect may not be present if the patient has not eaten recently (photo B)
Composition of the chyle: electrolytic content similar to plasma, > 1000 cells per L, including 80% of lymphocytes, presence of chylomicrons and > 110 mg / 100 ml of triglycerides.
Treatment:
- drainage (sometimes antenatal in congenital forms)
- enteral feeding with medium-chain triglycerides (not transported by the chylomicrons)
- parenteral nutrition and continuous infusion of octreotide (0.3 to 1 µg/kg/h) of somatostatin (3.5 to 10 µg/kg/h) or etilefrine
- in case of failure: thoracic duct ligation, pleurodesis (iodine povidone, 10 % if skin solution or 4% if scrub solution), temporary pleuro-peritoneal shunt
Anesthetic implications:
respiratory distress, hypoalbuminemia, malnutrition, depression of immunity (lymphopenia), sometimes increased risk for venous thrombosis
References :
- Wheeler AD, Tobias JD.
Tension chylothorax in two pediatric patients.
Pediatr Anesth 2007; 17:488-91.
- Wu ET, Takeuchi M, Imanaka H et al.
Chylothorax as a complication of innominate vein thrombosis induced by a peripherally inserted central catheter.
Anaesthesia 2006; 61:584-6.
- Downie L, Sasi A, Malhotra A.
Congenital chylothorax : associations and neonatal outcomes.
J Paediatr Child Health 2014 ; 50 : 234-8.
- Hmami F, Oulmaati A, Bouchilkhi C et al.
Chylothorax congénital : réponse rapide et totale à la polyvidone iodée.
Arch Pédiatr 2014 ; 21 : 1002-5.
- Tutor JD.
Chylothorax in infants and children.
Pediatrics 2014 ; 133 : 722-33
Updated: February 2017