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

Richard P Lion, Melissa M Winder, Rambod Amirnovin, Kristi Fogg, Rebecca Bertrandt, Priya Bhaskar, Cameron Kasmai, Kathryn W Holmes, Rohin Moza, Piyagarnt Vichayavilas, Erin E Gordon, Amiee Trauth, Megan Horsley, Deborah U Frank, Arabela Stock, Greg Adamson, Alissa Lyman, Tia Raymond, Isaura Diaz, Alicia DeMarco, Parthak Prodhan, Michael Fundora, Alaa Aljiffry, Aaron G Dewitt, Benjamin W Kozyak, Lawrence Greiten, Carly Scahill, Jason Buckley, David K Bailly

Journal: Cardiology in the young 2022;32(8):1202-1209

PMID: 35792060

Full Text on Ovid Technologies, Inc. View on PubMed

Abstract

OBJECTIVE

A standardised multi-site approach to manage paediatric post-operative chylothorax does not exist and leads to unnecessary practice variation. The 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%.

Address: Department of Pediatrics, Division of Pediatric Cardiac Critical Care, University of Texas, Austin, TX, USA.; Department of Pediatrics, Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT, USA.; Department of Pediatrics, Division of Pediatric Critical Care Medicine, Loma Linda University, Loma Linda, CA, USA.; Department of Pediatrics, Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC, USA.; Department of Pediatrics, Division of Pediatric Critical Care, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA.; Department of Pediatrics, Division of Critical Care Medicine, UT Southwestern Medical Center, Dallas, TX, USA.; Department of Pediatrics, Division of Pediatric Cardiology, OHSU Doernbecher Children's Hospital, Portland, OR, USA.; Department of Pediatrics, Division of Pediatric Cardiology, University of Colorado-Denver, Aurora, CO, USA.; Department of Pediatrics, Division of Pediatric Critical Care, University of Texas Southwestern, Dallas, TX, USA.; Department of Nutrition Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.; Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Virginia, Charlottesville, VA, USA.; Department of Pediatrics, Division of Cardiac Critical Care, Johns Hopkins All Children's, St Petersburg, FL, USA.; Department of Pediatrics, Division of Pediatric Cardiology, Stanford University/Lucile Packard Children's Hospital, Palo Alto, CA, USA.; Department of Pediatrics, Division of Cardiac Critical Care, Medical City Children's Hospital, Dallas, TX, USA.; Department of Pediatrics, Division of Critical Care Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN, USA.; Department of Pediatrics, Division of Anesthesiology/Critical Care Medicine, USC Keck School of Medicine, Los Angeles, CA, USA.; Department of Pediatrics, Division of Pediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA.; Department of Pediatrics, Division of Cardiology, Children's Healthcare of Aitlanta, Emory University School of Medicine, Atlanta, GA, USA.; Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Critical Care Medicine, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.; Department of Surgery, Division of Pediatric Cardiothoracic Surgery, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, 1 Children's Way, Little Rock, AR, USA.; Department of Pediatrics, Division of Pediatric Cardiology, University of Colorado, Denver, Aurora, CO, USA.; Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA.

DOI: 10.1017/S1047951122001871

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MeSH Terms: Cardiac Surgical Procedures, Child, Chylothorax, Humans, Postoperative Period