CP-071 Midodrine in refractory chylothorax after paediatric cardiac surgery

Abstract

BackgroundPostoperative chylothorax is usually the result of iatrogenic injury to the thoracic duct or surrounding collateral lymphatic ducts during surgery. There are currently no recommendations for the management of refractory cases to optimal medical and surgical interventions.PurposeTo describe a case of refractory chylothorax in which the alpha adrenergic stimulant midodrine was successfully used.Material and methodsRetrospective case report and literature search related to the treatment of refractory chylothorax review. Data source: electronic medical records and PubMed data and Uptodate.ResultsA 4-year-old girl (weight 16 kg) underwent extracardiac Fontan surgery, and at the postoperative period presented with high chylous output from chest tubes. In the beginning, conservative treatment based on pleural drainage and dietary measures (enteral/parenteral nutrition poor in fat and with medium chain triglycerides) was performed. On postoperative days 6 and 25, an octreotide infusion (dose range 1 to 12 μg/kg/h) was initiated for 17 and 42 days, respectively, showing reduction in chyle leak but not its resolution. On postoperative day 41, pleurodesis with 320 mg tetracycline (20 mg/kg) was performed and repeated for 2 more days. Later, on postoperative day 69, bilateral pleurodesis with talc was done but was not effective. In view of the lack of effectiveness of the above measures, a literature search was performed and an article that described the successful use of midodrine in an adult refractory case of chylothorax was found. Despite not finding any reference in the paediatric population, due to the state of malnutrition, immunosuppression and coagulopathy of the patient, it was decided to prescribe off-label midodrine at a dose of 1 mg/8 h. Treatment was continued for 16 days and the drained volume was reduced from 20 mL/h to imperceptible. No adverse effects related to treatment with midodrine were observed.ConclusionChylothorax is a possible complication after thoracic duct injury during cardiothoracic surgery. Therapeutic strategies should be based on pleural drainage, diet, octreotide and, in persistent cases, pleurodesis. Midodrine may be a therapeutic option when the above measures are not effective.References and/or AcknowledgementsLiou DZ, et al. Midodrine: a novel therapeutic for refractory chylothorax. Chest 2013;144:1055-7No conflict of interest.

Incidence and risk factors for chylothorax after pediatric heart surgeries: retrospective analysis of a large institution database​

“…We prescribed the midodrine 2.5 mg, Q12 hourly, and continued for 1 and half months. Some case reports are related to a substantial decrease in chyle output in which the midodrine dose was 1 mg, Q8 hourly [ 20 , 21 ]. In our study, both children underwent surgery.…”

Chylothorax in the neonate—A stepwise approach algorithm

“…Midodrine , an oral selective alpha‐1adrenoreceptor agonist, is a vasopressor that may be used as an adjunctive therapy to contract lymphatic vessels in patients with chylothorax 55 . It has been successfully used in adults, 56,57 a 4‐year‐old girl, 58 and a neonate 59 (LoE C).…”