A 59-year-old man was admitted in September 2008 with a diagnosis of postoperative chylothorax.
A history of sigma cancer, performing in July 2008 a liver metastasectomy, being necessary since then to perform various chylothorax evacuators (approximately extracted volume: 9,000 mL).
On admission, he reported asthenia, discomfort in the right hemithorax and mild respiratory distress.
Pleural effusion occupying two thirds of the right hemithorax was radiologically observed.
After a pleural drainage, 500 mL of a fluid with a quotient appearance was obtained in the first 24 hours, whose analysis was compatible with chylothorax3: cholesterol (COL) 60 mg/dL, pleural triglycerides (TG).
Conservative treatment was decided with absolute diet and chest drainage, consulting the Nutrition Area to start parenteral nutritional support.
1.
Nutritional assessment showed a 4% weight loss in the last two months (usually 74 kg; current 71 kg), albumin 2.6 g/dL, transferrin 154 mg/dL, C-reactive protein (CRP) 16.6 mg/dL.
The patient presented slight loss of fat and muscle mass, together with reduced functional capacity in the last weeks; absence of edema, malleolus and signs or symptoms of specific subcutaneous deficit at home.
Dietary history without recent changes.
The nutritional situation was compatible with mild protein-energy malnutrition, considering the following plan of nutritional care:
• Objectives: To maintain the gastrointestinal tract at rest and prevent a higher degree of malnutrition in a patient with high nutrient losses by pleural drainage
• Nutritional requirements: Caloric needs estimated by the Berris-Benedict equation (correction factor 1.4), 2200 kcal/day; protein requirements 1.5 amino acids/kg/day
• Composition of parenteral nutrition formula (PN): Volume 2,500 ml; 120 g of amino acids; 300 g of glucose; 60 g of lipids (MCT/LCT); 2280 kcal total; vitamins and oligoelements
Despite treatment, pleural drainage remained stable in the first days, with a chylous appearance persisting.
The ultrasound showed loculated pleural effusion resulting in 200,000 IU urokinase for two consecutive days by the digestive endoscopy tube.
Because of persistent abundant chylous drainage, it was decided to start treatment with octreotide 100 mcg/8h subcutaneously.
Drainage was progressively reduced in the following days, changing to a serous aspect.
At the same time, the patient's general condition worsened, with abdominal discomfort, oliguria and hyperglycemia.
Suspicion of adverse reaction to octreotide was discontinued on day 4.
Biochemistry showed anemia (hemoglobin 9.4 g/dL; hematocrit 28.8%), leucopenia (2,390 leukocytes/microliters), thrombocytopenia (48,000/microliters), urea 59 mg/dL, total creatinine 0.6 mg/dL
1.
After discontinuation of octreotide, pleural drainage continued to decrease to 50 mL/24h, maintaining the serous aspect.
On day 19 of admission mixed feeding was started using mixed formula with fat (Clinut®; 1.25 kcal/mL); 13%dura proteins or diet with fat mL (Clinutut®; 1.25 kcal/mL); fruit pure juices.
In subsequent days, NE increased progressively up to 50% of estimated calorie needs (1,000 mL/day), diet was progressed with the introduction of roasted bread, skimmed-milk, gutted white fish or bread,
Parallel to this, inputs were reduced with PN.
On day 22, after 48 hours with no changes in pleural drainage, the stenting tube and the PN were removed.
The nutritional evolution was favorable, with a gain of 2 kg, not being able to objective improvement in visceral proteins in the persistence of high CRP (15.7 mg/dL).
At discharge, it was recommended to follow the same diet supplemented with a spoonful of sopera daily (10 g) sunflower oil to prevent essential fatty acid (AGE) deficiency.
