Octreotide for the treatment of chylothorax in neonates. Skip sharing on social media links. Authors. Animitra Das. Prakeshkumar S Shah. Background - Methods - Results - Characteristics of Included Studies - References - Data Tables & Graphs. Department of Pediatrics, Waterford Regional Hospital, Waterford, Ireland . Octreotide for the treatment of chylothorax in neonates. Cochrane Database of Systematic Reviews 2. Issue 9. DOI: 1. 0. Chylothorax, a relatively rare complication of thoracic surgery, mostly occurs on the right side. We present a 16-year-old male who received thoracoscopic surge. It may include periodic removal of built-up fluid, a low-fat diet, and, possibly. Conservative Management of Chylothorax after Coronary Artery Bypass Grafting. Somatostatin, OK-432, octreotide (a long-act -.
CD0. 06. 38. 8. pub. Contact person. Prakeshkumar S Shah. Department of Paediatrics and Department of Health Policy, Management and Evaluation, Rm 7. AUniversity of Toronto. University Avenue. Toronto Ontario M5. G 1. XBCanada. E- mail: pshah@mtsinai. Dates. Assessed as Up- to- date: 0. July 2. 01. 0Date of Search: 0. March 2. 01. 0Next Stage Expected: 0. July 2. 01. 2Protocol First Published: Issue 1, 2. Review First Published: Issue 9, 2. Last Citation Issue: Issue 9, 2. What's new. History. Abstract. Background. Routine care for chylothorax in neonate includes either conservative or surgical approaches. Octreotide, a somatostatin analogue, has been used for the management of patients with refractory chylothorax not responding to conservative management. Objectives. To assess the efficacy and safety of octreotide in the treatment of chylothorax in neonates. Search methods. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE and EMBASE (to March 7, 2. We assessed the reference lists of identified trials and abstracts from the annual meetings of the Pediatric Academic Societies published in Pediatric Research (2. Selection criteria. We planned to include randomised or quasi- randomised controlled trials of octreotide in the treatment of congenital or acquired chylothorax in term or preterm neonates, with any dose, duration or route of administration. Data collection and analysis. Data on primary (amount of fluid drainage, respiratory support, mortality) and secondary outcomes (side effects) were planned to be collected and analysed using mean difference, relative risk and risk difference with 9. Results. No randomised controlled trials were identified. Nineteen case reports of 2. Fourteen case reports described successful use (resolution of chylothorax), four reported failure (no resolution) and one reported equivocal results following use of octreotide. The timing of initiation, dose, duration and frequency of doses varied markedly. Gastrointestinal intolerance and clinical presentations suggestive of necrotizing enterocolitis and transient hypothyroidism were reported as side effects. Authors' conclusions. No practice recommendation can be made based on the evidence identified in this review. A prospective registry of chylothorax patients and a subsequent multicenter randomised controlled trial are needed to assess the safety and efficacy of octreotide in the treatment of chylothorax in neonates. Plain language summary. Octreotide for treatment of chylothorax in newborns. Collection of lymphatic fluid in the chest cavity is called chylothorax. Routine management of this condition involves treatment of the underlying condition, draining of fluid, putting a tube in the chest wall until all the fluid is drained and rarely surgery. Octreotide is a drug that may reduce the production and accumulation of fluid and allow babies to recover faster. No trials have evaluated the safety and efficacy of this drug in babies and only case reports are available. Future studies are needed. Chyle is composed of fats (phospholipids, cholesterol and triglycerides), proteins (albumin, immunoglobulins and fibrinogen), electrolytes, fat soluble vitamins and lymphocytes. The diagnosis of chylothorax is considered when pleural fluid assay has a triglyceride level > 1. L and total cell count of > 1. Without oral fat intake, the distinction between chylous and non- chylous effusion is difficult because chylomicrons are absent in the pleural fluid (Buttiker 1. In non- feeding infants, the diagnosis of chylothorax is made by identifying the presence of a high number of lymphocytes in serous fluid. Chylothorax can be unilateral or bilateral and congenital or acquired. Congenital chylothorax is associated with abnormalities of the lymphatic system such as lymphangiomatosis and lymphangiectasia, congenital heart disease, mediastinal malignancies, chromosomal abnormalities (trisomy 2. Turners and Noonan syndromes) and H- type of tracheoesophageal fistula (Rasiah 2. Acquired chylothorax is usually due to trauma to the thoracic duct during cardiac or thoracic surgery. The incidence of congenital chylothorax is reported to be 1 in 1. Rennie 1. 99. 9). Many cases of chylothorax have no clear etiology and are considered as idiopathic congenital chylothorax (Au 2. The reported case fatality rate is 1. Brissaud 2. 00. 3 ). Significant in- utero chylothoraces may impair lung development and result in pulmonary hypoplasia. Attempts to treat chylothorax by drainage may lead to malnutrition, electrolyte imbalance and infection (Wasmuth 2. Antenatal management of chylothorax consists of thoracentesis or pleuro- amniotic shunts to prevent pulmonary hypoplasia. In the postnatal period, the management of the pleural effusion can be either conservative or surgical. The conservative approach includes management of underlying disease, repeated thoracentesis, continuous drainage, dietary modifications (medium chain triglyceride diet or total parental nutrition), use of positive end expiratory pressure during mechanical ventilation and chemical or mechanical pleurodesis. The surgical approach includes thoracoscopic pleurodesis, pleuroperitoneal pump, surgical abrasion, ligation of the thoracic duct and creation of a thoracic duct to azygous vein anastomosis (Brissaud 2. None of these therapeutic modalities have undergone controlled clinical trials; however these treatments are commonly used in the clinical setting. Description of the intervention. Octreotide, a somatostatin analogue, is used for the management of patients with refractory chylothorax, not responding to conservative management (Goto 2. The use of octreotide in the treatment of chylothorax in infants and children has been reviewed (Helin 2. Roehr 2. 00. 6). Both reviews suggested that octreotide has the potential to be a potent and effective therapy for chylous pleural effusion. However, it has not been studied in randomised trials. Octreotide has been used for a variety of indications in adults and older children including acromegaly, carcinoid tumour, acute variceal bleeding, gastrointestinal fistulae and intractable diarrhoea (Lamberts 1. In neonates, octreotide has been used for the management of persistent hyperinsulinaemic states (Glaser 1. How the intervention might work. The mechanism of action of octreotide in chylothorax is uncertain. It is proposed that octreotide causes mild vasoconstriction of splanchnic vessels, including hepatic venous flow. This leads to reduction in gastric, pancreatic and intestinal secretions as well as intestinal absorption. These mechanisms collectively reduce the flow of chyle (Rasiah 2. Animal studies have shown that octreotide is effective in treating thoracic duct injury by reducing the chyle drainage and allowing early fistula closure (Markham 2. However, octreotide is associated with adverse effects such as arrhythmias, injection site pain, nausea, vomiting, constipation or diarrhoea, hyperglycaemia, hypoglycaemia, dizziness and fatigue (Buck 2. Other adverse effects include transient impairment of liver function, transient hypothyroidism and necrotizing enterocolitis (Mohseni- Bod 2. Maayan- Metzaer 2. Arevalo et al reported octreotide induced hypoxaemia and pulmonary hypertension in preterm neonates (Arevalo 2. Why it is important to do this review. Despite the reported benefit in reduction of chyle production in uncontrolled case studies, octreotide has not been systematically evaluated in newborns with chylothorax. Moreover, the safety profile in relation to adverse effects, dosing schedule, route of administration and duration of therapy has not been evaluated. Objectives. Our primary objective was to assess the efficacy and safety of octreotide in the treatment of chylothorax in neonates. Our secondary objective was to perform subgroup analyses based on: gestation (preterm or term); route of administration of octreotide; congenital or acquired chylothorax; timing of introduction of octreotide (< 7 days or 7 days of diagnosis). Cross- over trials were not included. Unpublished data and abstracts were eligible for inclusion provided adequate information regarding primary or secondary outcomes could be obtained. Types of participants. Both term and preterm (< 3. Studies were included if pleural fluid was confirmed to be of chylous origin. If feeds had not been initiated, infants were included if pleural fluid showed more than 8. In milk- fed infants, the standard criteria for laboratory diagnosis of chyle were used. Types of interventions. Octreotide versus placebo or no treatment added to the current conservative management. Studies of any route of administration, any dose and any duration of administration of octreotide were considered. Types of outcome measures. Primary outcomes. Change in the amount of chyle production from baseline to end of treatment (ml/day). Number of days of respiratory support after initiation of octreotide therapy: number of days of mechanical ventilation, number of days of continuous positive airway pressure (CPAP), number of days of oxygen therapy. Duration of hospital stay (days). Mortality before 2. Secondary outcomes. Total number of days of chest drain insertion (removal of both chest drains in cases of bilateral effusion). Number of infants requiring surgical intervention: thoracoscopic pleurodesis, pleuroperitoneal pump, ligation of the thoracic duct, creation of a thoracic duct to azygous vein anastomosis. Number of days to reach full enteral feeds. Sepsis. Necrotizing enterocolitis (Bell's criteria, Stage 2).
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