uvbogden

If feedings are appropriate, an initial trial of MCT-rich, otherwise low fat, feedings is given. If chylothorax doesn't resolve in a week or so, the infant is made NPO and provided nutrition with TPN. If chylothorax continues to drain for more than 2-3 weeks, a trial of octreotide, which decreases chyle flow, might be considered on a case by case basis, knowing it can also reduce G.I. bloodflow. Neonates with prolonged chylothorax failing to resolve with all previous measures may be considered for chemical pleurodesis with agents such as povidone iodine or doxycycline. Alternatively, Pediatric Surgery consultation might be obtained in consideration of possible thoracic duct ligation or embolization. Blocking the main channel, into which most lymphatics flow, just above the level of the diaphragm, can stop the chyle leakage that occurs higher in the thoracic duct where chyle enters the pleural space. Lymph flow continues via collateral lymphatics Fluid losses are replaced and electrolytes are managed as needed. If serum albumin falls below normal, IV albumin or FFP is given (clotting factors can also become depleted). IVIg can be given for low immunoglobulins. Even a few days of chylothorax drainage can remove a significant number of lymphocytes, and lymphopenia can put the neonate at risk for infection, especially those that require intubation/mechanical ventilation, and have indwelling central lines and chest tubes. Other than monitoring circulating lymphocyte numbers and observing for signs of infection, I'm wondering what others do to deal with this complication of chylothorax. If you encounter severe lymphopenia, do you consider prophylactic antibiotics? If so which would you choose, and do you then worry about opportunistic fungal infection?

I have seen these LMAs in resuscitation carts since Pediatric Residency, but I've never seen one used. It was always emphasized during my training that any baby can be provided adequate ventilation with a bag and mask until intubation can be accomplished. Intubation skills were a priority. Of course, that was before surfactant. In the years since training I've worked in a number of L2 and L3 NICUs and never has the question of using an LMA come up. I'm intrigued, however, by the possibility of delivering surfactant without subjecting the newborn to otherwise unnecessary intubation.