A 59-year-old man who was admitted in September 2008 with a diagnosis of post-surgical chylothorax. He had a history of sigmoid cancer, having undergone a liver metastasectomy in July 2008, and since then several thoracentesis to evacuate the chylothorax (approximate volume extracted: 9,000 mL).
On admission, he reported asthenia, discomfort in the right hemithorax and mild respiratory distress. A pleural effusion occupying two thirds of the right hemithorax was radiologically observed. After placement of a pleural drain, 500 mL of milky fluid were obtained in the first 24 hours, the analysis of which was compatible with chylothorax3: cholesterol (COL) 60 mg/dL, triglycerides (TG) 515 mg/dL, COL pleural fluid/serum ratio: 0.28; TG pleural fluid/serum ratio: 3.18. Conservative treatment with absolute diet and thoracic drainage was decided, and the Nutrition Department was consulted to initiate parenteral nutritional support.

The nutritional assessment showed a weight loss of 4% in the last two months (usual 74 kg; current 71 kg), albumin 2.6 g/dL, transferrin 154 mg/dL, C-reactive protein (CRP) 16.6 mg/dL. Slight loss of subcutaneous fat and muscle mass, together with reduced functional capacity at home in recent weeks; absence of malleolar oedema and signs or symptoms of specific vitamin deficiencies. Dietary history with no recent changes.
The nutritional situation was compatible with mild protein-energy malnutrition, and the following nutritional care plan was proposed:
- Objectives: To maintain the gastrointestinal tract at rest and prevent further malnutrition in a patient with high nutrient losses through pleural drainage
- Nutritional requirements: Calorie requirements estimated by Harris-Benedict equation (correction factor 1.4) of 2,200 kcal/day; protein requirements 1.5-1.7 g/kg/day of amino acids; standard micronutrient requirements.
- Composition of parenteral nutrition (PN) formula: Volume 2500 ml; 120 g amino acids; 300 g glucose; 60 g lipids (MCT/LCT); 2280 kcal total; vitamins and trace elements according to AMA-ASPEN recommendations.
Despite treatment, pleural drainage remained stable in the first few days, with a chylous appearance persisting. Ultrasound showed loculated pleural effusion, and 200,000 IU of urokinase was administered for two consecutive days through the thoracentesis tube. Given the persistence of abundant chylous drainage, it was decided to start treatment with octreotide, at a dose of 100 mcg/8 h subcutaneously. The drainage progressively reduced over the following days, changing to a serous appearance. At the same time, the patient's general condition worsened, with abdominal distension, oliguria and hyperglycaemia. On suspicion of an adverse reaction to octreotide, treatment was discontinued on the 4th day of treatment. Biochemistry showed anaemia (haemoglobin 9.4 g/dL; haematocrit 28.8%), leucopenia (2,390 leucocytes/microlitres), thrombocytopenia (48.000/microlitres), urea 59 mg/dL, creatinine 0.6 mg/dL, total bilirubin 1.4 mg/dL (direct 1.2 mg/dL), GOT 76 IU/L, GPT 61 IU/L, gGT 502 IU/L, FA 136 IU/L, CRP 29.8 mg/dL.

After discontinuation of octreotide, pleural drainage continued to decrease until it was reduced to 50 mL/24h, maintaining the serous aspect. On the 19th day of admission, mixed feeding was started using oral enteral nutrition (EN) with a fat-free formula (Clinutren Fruit®; 1.25 kcal/mL; 13% protein, 87% carbohydrates; 600 mL/day), together with a low-fat oral diet (boiled or mashed vegetables and potatoes, natural fruit, fruit juice or compote, infusions). On subsequent days, NE was progressively increased to 50% of the estimated calorie needs (1000 mL/day), the diet was progressed with the introduction of toasted bread, boiled or grilled white fish, salad and skimmed milk, and supplemented with MCT oil (up to 60 g/day, in salads and bread). At the same time, the intake of PN was reduced. On day 22, after 48 hours without changes in pleural drainage, the thoracentesis tube and PN were removed.
Nutritional evolution was favourable, with a weight gain of 2 kg, but no improvement in visceral proteins was observed due to persistently high CRP (15.7 mg/dL). At discharge, the patient was advised to follow the same diet supplemented with a tablespoonful (10 g) of sunflower oil per day to prevent essential fatty acid (EFA) deficiency.

