Development of consensus recommendations for the management of post-operative chylothorax in paediatric CHD
Richard P Lion1, Melissa M Winder2, Rambod Amirnovin3
1Department of Pediatrics, Division of Pediatric Cardiac Critical Care, University of Texas, Austin, TX, USA.
Insights
A new algorithm standardizes the management of pediatric post-operative chylothorax. This quality improvement initiative achieved over 80% consensus among experts, improving care consistency for children after cardiac surgery.
Area of Science:
- Pediatric Critical Care
- Cardiothoracic Surgery
- Medical Algorithm Development
Background:
- Lack of standardized multi-site approach for pediatric post-operative chylothorax management.
- Significant practice variation exists, impacting patient outcomes.
- Need for a unified management strategy.
Purpose of the Study:
- To develop a standardized algorithm for managing pediatric post-operative chylothorax.
- To address practice variation through a multi-disciplinary, multi-site quality initiative.
- To establish consensus on chylothorax management recommendations.
Main Methods:
- Convened over 60 multi-disciplinary providers from 22 centers virtually.
- Developed a management algorithm for pediatric post-operative chylothorax.
- Quantified agreement using anonymous surveys, defining consensus as ≥80% agreement.
- Validated understanding through ex vivo simulations.
Main Results:
- The algorithm covers children (<18 years) within 30 days of cardiac surgery.
- Includes 11 recommendations on diagnosis, diet modification, and medical therapy.
- All recommendations achieved >80% consensus (81-100%).
- Ex vivo simulations showed high understanding (73-100%).
Conclusions:
- First multi-site algorithm for pediatric post-operative chylothorax management.
- Algorithm features transparent, objective measures of agreement and understanding.
- Achieved >80% expert agreement and 94% overall understanding.
Objective:
A standardised multi-site approach to manage paediatric post-operative chylothorax does not exist and leads to unnecessary practice variation. The Chylothorax Work Group utilised the Pediatric Critical Care Consortium infrastructure to address this gap.
Methods:
Over 60 multi-disciplinary providers representing 22 centres convened virtually as a quality initiative to develop an algorithm to manage paediatric post-operative chylothorax. Agreement was objectively quantified for each recommendation in the algorithm by utilising an anonymous survey. "Consensus" was defined as ≥ 80% of responses as "agree" or "strongly agree" to a recommendation. In order to determine if the algorithm recommendations would be correctly interpreted in the clinical environment, we developed ex vivo simulations and surveyed patients who developed the algorithm and patients who did not.
Results:
The algorithm is intended for all children (<18 years of age) within 30 days of cardiac surgery. It contains rationale for 11 central chylothorax management recommendations; diagnostic criteria and evaluation, trial of fat-modified diet, stratification by volume of daily output, timing of first-line medical therapy for "low" and "high" volume patients, and timing and duration of fat-modified diet. All recommendations achieved "consensus" (agreement >80%) by the workgroup (range 81-100%). Ex vivo simulations demonstrated good understanding by developers (range 94-100%) and non-developers (73%-100%).
Conclusions:
The quality improvement effort represents the first multi-site algorithm for the management of paediatric post-operative chylothorax. The algorithm includes transparent and objective measures of agreement and understanding. Agreement to the algorithm recommendations was >80%, and overall understanding was 94%.
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