Week 6 Hypermetabolism: Chylorthorax Flashcards
What is chylothorax?
a lymphatic flow disorder
* A rare condition in which lymphatic fluid leaks into the space between the lung and chest wall.
What is chyle?
lymphatic fluid containing fat that is formed in the
lacteals of the intestine during digestion.
* Chyle is transported through the lymphatics and enters the venous circulation via the thoracic duct and is the method by which approximately 70% of ingested fat enters the circulation after digestion.
When can chylothorax occur?
occurs when damage to the lymphatic ducts in the thoracic cavity results in leakage of chyle into the chest cavity (thoracic cavity).
What is chylous Ascites?
Occurs when damage to the lymphatic ducts in the peritoneal cavity occurs as well; leading to the leakage of chyle into the peritoneal cavity. This can result in abdominal ascites or chylous ascites.
Characteristics of chyle
- made up of mostly lipids so white; if something is leaking white want to check if it is chyle
- has a fair amount of electrolytes
- chyle is also very alkaline so can be very damaging
Surgical and Medical
Etiology of chylothorax
- Amyloidosis (amyloid builds up in organs)
- Congenital chylothorax
- Coronary artery bypass grafting
- Coughing (violently) from a meal; rare, but possible
- Malignancies/ lymphomas (probably one of most common reasons)
- Neck, thoracic/cardiac surgery
- TB and other infectious process
- Thrombosis of L-subclavian vein
Etiology of chylous ascites
Malignancies
* lymphomas
* carcinomas (ovarian, colon, gastric)
post operative
* abdominal aortic injury
* liver transplantation
* cirrhosis
* spont. abdominal bacterial peritonititis
* congenital abnormalities of lymphatic system
TB and other infectious processes
Signs and Symptoms of Chylous
Ascites in the Peritoneum
- abdominal distension
- ↑ abdominal girth
- Dyspnea
- Increasing drainage from pertioneal cavity (white drainage; positive for TAGs/ chylomicrons)
Adverse clinical effects of Chylous
Ascites
- Electrolytes inbalances hyponatremia, hypocalcemia
- hypovolemia, hypoproteinemia
- hemodynamic instability
- metabolic acidosis
- ↑ risk of bacterial and viral sepsis
- ↑ Electrolytes inbalances
- ↑ morbidity
- altered protein & fat metabolism
- deteriorated nutritional status (depleted body protein & reserves of fat and vitamins)
- compromised immunologic function due to lymphocytes loss
Principles of treatment for chylothorax
Consider the cause and then treat from there
* surgery (risky but can try to block the leak)
* prevent and treat compications
* initial drainage
* dietary modifications: free-fat/MCT/TPN
* somatostatin, octreotide
clinical/ localized effect of
sustained chyle leak
- Adverse clinical effects depend upon the amount of the leak, rate and duration of flow, size of the cavity and clinical/nutritional management of patient
- Localized effects: cardiac and pulmonary dysfunction
Nutrition Management for Chylous
Leak
- Conservative management: NPO with PN, treatment with meds and/or surgery. When output is > 1000 ml/24 hrs usually TPN is needed.
- Feed orally with lower fat (very low LCT-MCT predominant EN Formula)
- If persistent leakage (>500 mls/d); go to OR for corrective surgery
Which weight to use in fluid overload
Use estimate of dry weight to calculate fluid needs in the case of fluid overload; regardless of degree of malnutrition/over-nutrition
* NEVER use actual weight in fluid overloaded individual to calculate fluid needs. the wet weight (actual weight in fluid overload) could be > ideal
body weight. This is why it is better to use estimate of dry weight
* If patient is fluid overloaded and underweight: always best to use the dry weight calculation for protein/energy equations; but compare to ideal body weight. Unlikely that dry weight > ideal body weight (unless the patient is adequately nourished).
* many patients with this condition are at high risk for refeeding syndrome.
Which weight to use in over-nutrition
What happens when dry weight > ideal body weight…use ideal body weight
* except when fluid overload; then use dry weight for fluid calculations, and ideal body weight to calculate energy and protein needs
