Chylothorax after surgery for congenital heart disease.

PURPOSE OF REVIEW: Postoperative chylothorax is a frequently encountered pathology in the cardiac intensive care unit. The continuous loss of chyle is a challenging problem to treat and is associated with increased morbidity and mortality. The purpose of this article is to review the pathophysiology of chylothorax in patients after surgery for congenital heart disease, its implications and the current therapies available. RECENT FINDINGS: The incidence of chylothorax has been increasing over the last two decades. Multiple uncontrolled case series describe octreotide as an effective treatment, and octreotide usage is increasing around the world for patients nonresponsive to dietary modifications. Most centers reserve surgical treatment for patients nonresponsive after 4 weeks of medical treatment. Less-invasive surgical procedures such as thoracic duct ligation by video-assisted thoracoscopy are gaining popularity. SUMMARY: Chylothorax is commonly seen in children after surgery for congenital heart disease. The multiple and serious complications associated with chylous effusions are well known. Conservative therapy with diet modification and octreotide remain the standard initial approach. Thoracic duct ligation has been reported as a highly successful treatment but has considerable risk. Thus, this procedure should be reserved for patients nonresponsive to conservative therapy.

Diagnosis influences response of cerebral near infrared spectroscopy to intracranial hypertension in children.

OBJECTIVE: To describe cerebral regional oxygen saturation measured by near infrared spectroscopy in the setting of normal and increased intracranial pressure in children to evaluate the association between cerebral regional oxygen saturation and intracranial pressure in comparison with other clinical variables. DESIGN: Prospective observational cohort study. SETTING: Two academic tertiary care centers' pediatric intensive care units. PATIENTS: Thirty patients with intracranial pressure and near infrared spectroscopy monitoring (median age, 11.5 yrs; interquartile range, 5.2-13 yrs) for a range of neurologic diagnoses, including brain tumor, trauma, intracerebral hemorrhage, and hydrocephalus. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Temporally correlated cerebral regional oxygen saturation with hematologic (hematocrit), biochemical (pH), and physiological (intracranial pressure, mean arterial pressure, cerebral perfusion pressure, temperature, heart rate, pulse oximetry and end-tidal carbon dioxide) variables. Cerebral regional oxygen saturation during episodes of increased intracranial pressure was lower than with normal intracranial pressure (mean +/- sd intracranial pressure >20 = 71% +/- 13% vs. intracranial pressure <20 = 75% +/- 10%), although the mean difference (-4%) is small compared with variability in the measurement. Neither isolated values nor change in cerebral regional oxygen saturation were significantly associated with intracranial pressure or cerebral perfusion pressure in the overall population. Isolated values and change in end-tidal CO2 were significantly correlated with cerebral regional oxygen saturation and change in cerebral regional oxygen saturation (all p < 0.01). In exploratory analyses, the diagnostic group significantly modified the effect of intracranial hypertension on regional oxygen saturation: regional oxygen saturation decreased during intracranial hypertension in patients with brain tumors (p = .05) and hydrocephalus (p < .001) but increased during intracranial hypertension in those with intracranial hemorrhage (p < .001). CONCLUSIONS: These data suggest that cerebral regional oxygen saturation is lower with intracranial hypertension. However, the relationship between cerebral regional oxygen saturation and intracranial pressure is strongly influenced by diagnosis.