The role of pleurodesis in the management of chylous pleural effusion after surgery for congenital heart disease

Pleurodesis using OK-432 for persistent pleural effusion after cardiac surgery in the neonatal period or early infancy

OBJECTIVE

To evaluate the efficacy of pleurodesis using OK-432 after cardiac surgery in the neonatal period or early infancy.

METHODS

We retrospectively reviewed the data of 11 consecutive patients who underwent cardiac surgery in the neonatal period or early infancy and pleurodesis using OK-432 for persistent postoperative pleural effusion in two institutions.

RESULTS

The median age at surgery was 8 days (interquartile range [IR], 2-18) with a body weight of 2.84 kg (IR, 2.30-3.07). The maximum amount of pleural drainage before pleurodesis was 94.7 (IR, 60.2-107.7) ml/kg/day. Pleurodesis was initiated at postoperative day 20 (IR, 17-22) and performed in bilateral pleural spaces in seven patients and unilateral in four. The median numbers of injection were 4 (IR, 3-6) times per patient and 3 (IR, 2-3) times per pleural space. In 10 patients, pleural effusion was decreased effectively, and drainage tubes were removed without reaccumulation within 15 (IR, 12-28) days after initial pleurodesis. However, in one patient, with severe lymphedema, pleural effusion was uncontrollable, resulting in death due to sepsis. Adverse events were observed in nine patients; temporal deterioration of lung compliance and arterial blood gas occurred in two, insufficient drainage requiring new chest tube(s) in five, temporal atrial tachyarrhythmia in one, and lymphedema in four.

CONCLUSIONS

Pleurodesis using OK-432 is effective and reliable for persistent postoperative pleural effusion in neonates and early infants. Most of the complications, which derived from inflammatory reactions, were temporary and controllable. However, severe lymphedema is difficult to control.

Factors Associated with Readmission of Patients with Congenital Heart Disease in a Swiss University Hospital

Congenital heart defects (CHD) lead to extensive use of healthcare resources. Still, there is little information available regarding readmission rates or associated factors. We sought to evaluate readmission rates and their determinants among patients with CHD hospitalized in a Swiss university hospital. We conducted a retrospective study using data from all non-adult (<18 years) patients hospitalized between 2002 and 2014 at the University Hospital of Lausanne with an International Classification of Diseases version 10 code Q20-Q25. Overall, 996 patients (460 girls, 332 undergoing surgery, mean age 2.7 years) were assessed, 96 of whom (9.6%) were readmitted within 30 days after discharge. Among the 96 readmissions, 83 (86.5%) were related to the CHD. Median time to readmission was 10 days (interquartile range 6-20) and median length of readmission was 12 days (interquartile range 6-20). After multivariate adjustment, foreign nationality, greater distance to hospital and length of index hospitalization <14 days predisposed to readmission. Patients who underwent surgery were less likely to be readmitted (8.7%). We conclude that readmissions were frequent, almost 1 in 10 patients, and associated with several socio-clinical factors. Providing patients who live far from hospital with specialized care closer to home may help reduce the rate of readmission.

Chylothorax development in infants and children in the UK

AIM

To describe the incidence, patient profile, management strategies and outcome for infants and children who developed a chylothorax in the UK.

METHODS

A prospective study of infants and children ≥24 weeks' gestation - ≤16 years, who developed a chylothorax in the UK and were reported through the British Paediatric Surveillance Unit (BPSU). Clinicians completed a questionnaire on the presentation, diagnosis, management and outcome of these children. Three further data sources were accessed to confirm these data.

RESULTS

The incidence in children in the UK was 0.0014% (1.4 per 100,000) and 3.2% (3200 per 100,000) for those developing a chylothorax following a cardiac surgical procedure. The incidence was highest in infants ≤12 months at 16 per 100,000 (0.016%). A total of 219 questionnaires were returned with 172 cases meeting the eligibility criteria. Development of a chylothorax was most commonly associated with cardiac surgical procedure (65.1%) and was most frequently confirmed by laboratory verification of triglyceride content of the pleural fluid ≥1.1 mmol/L (66%). Although a variety of management strategies were employed, treatment with an intercostal pleural catheter (86.5%) and a medium chain triglyceride (MCT) diet (89%) was most commonly reported. The majority of the children had a prolonged hospital stay with a reported mortality of 12.2%.

CONCLUSIONS

Development of a chylothorax in infants and children in the UK was not common. The primary association was with a cardiac surgical procedure. The child's hospital stay was lengthy and therefore the impact on the child, family and hospital resources were significant. Common management strategies existed but national guidance is required to optimise practice. This study allows for better information relating to this serious complication to be given to patients and families and provides the basis for future research and practice development.

Successful pleurodesis with OK-432 in preterm infants with persistent pleural effusion

OK-432 (picibanil) is an inactivated preparation of Streptococcus pyogenes that causes pleurodesis by inducing a strong inflammatory response. Intrapleural instillation of OK-432 has recently been used to successfully treat neonatal and fetal chylothorax. Here we report a trial of intrapleural instillation of OK-432 in two preterm infants who were born with hydrops fetalis and massive bilateral pleural effusion. Both cases showed persistent pleural effusion, refractory to conservative treatment, up to postnatal days 26 and 46, respectively. An average of 80 to 140 mL of pleural fluid was drained daily. In case 1, the infant was treated with OK-432 during the fetal period at gestation 28 weeks and 4 days of gestation, but showed recurrence of pleural effusion and progressed into hydrops. Within two to three days after OK-432 injection, the amount of pleural fluid drainage was dramatically decreased and there was no reaccumulation. We did not observe any side effects related to OK-432 injection. We suggest that OK-432 should be considered as a therapeutic option in infants who have persistent pleural effusion for more than four weeks, with the expectation of the early removal of the chest tube and a good outcome.