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Fat Embolism Syndrome (FES)

Fat Embolism Syndrome (FES). Eva Xia Spring 2010. Some definitions…. Fat Emboli: F at particles or droplets that travel through the circulation Fat Embolism : A process by which fat emboli passes into the bloodstream and lodges within a blood vessel.

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Fat Embolism Syndrome (FES)

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  1. Fat Embolism Syndrome (FES) Eva Xia Spring 2010

  2. Some definitions… Fat Emboli: Fat particles or droplets that travel through the circulation Fat Embolism: A process by which fat emboli passes into the bloodstream and lodges within a blood vessel. Fat Embolism Syndrome (FES): serious manifestation of fat embolism occasionally causes multi system dysfunction, the lungs are always involved and next is brain

  3. Causes of FES • Blunt Trauma • Long bone (Femur, tibia, pelvic) factures

  4. Causes of FES • Non Trauma: agglutination of chylomicrons and VLDL by high levels of plasma CRP. • disease-related • Diabetes, acute pancreatitis, burns, SLE, sickle cell crisis • drug-related • parenteral lipid infusion • procedure-related • Orthopedic surgery, liposuction

  5. Pathophysiology of FES Exact mechanism unknown, but two main hypothesis • Mechanical Hypothesis • Biochemical Hypothesis

  6. Mechanical Hypothesis Obstruction of vessels and capillaries • Increase in intermedullary pressure forces fat and marrow into bloodstream • Bone marrow contents enter the venous system and lodge in thelungs as emboli • Smaller fat droplets may travel through the pulmonary capillaries into the systemiccirculation: Embolization to cerebral vessels or renal vessels also leads to central nervous system and renal dysfunction

  7. Biochemical Hypothesis Toxicity of free fatty acids • circulating free fatty acids directly affectthe pneumocytes, producing abnormalities in gas exchange • Coexisting shock, hypovolemia and sepsis impair liver function and augment toxic effects of free fatty acids

  8. Clinical Manifestations Asymptomatic for the first 12-48 hours Pulmonary Dysfunction • Respiratory Failure and ARDS (tachypnea, dyspnea, crackles, cyanosis) • Hypoxemia • systemic arterial hypotension, a decrease in cardiac output, and arrhythmias Neurological (nonspecific) • acute confusion, headache, stupor, coma, rigidity or convulsions Dermatological Signs • A reddish brown petechial rash within 24-36 hours • distributed to the upper body, chest, neck, upper arm, axilla, shoulder, oral mucous membranes and conjunctivae

  9. Clinical Manifestation

  10. Diagnosis • Clinical examination preferred over diagnostic

  11. Laboratory Studies • Arterial Blood Gases (ABGs) • Urine and sputum examination • Haemotological Tests • Biochemical tests

  12. Imagining • Chest x-ray • shows multiple flocculent shadows (snow storm appearance). picture may be complicated by infection or pulmonary edema. • CT Scan brain • may be normal or may reveal diffuse white-matter petechialhaemorrhages • Helical CT Scan chest • may be normal as the fat droplets are lodged in capillary beds. Can detect lung contusion, acute lung injury, or ARDS may be evident.

  13. Chest X-ray ER admit AP & expiratory film so we cannot comment on cardiac shadow. However, there is no evidence of lung contusion, pneumo, haemo or pneumohaemothorax. SICU admit (12 hours later) upper lobe diversion and bilateral pulmonary infiltrates Altaf Hussain: “A Fatal Fat Embolism.” The Internet Journal of Anesthesiology, 2004. Volume 8 Number 2.

  14. MRI showing foci of ischemia suggestive of fat embolism syndrome post operative day 2 showing multiple hyperintense areas consistent with multiple emboli post operative day 14 and shows evolving cortical infarctions Source:http://www.ispub.com/journal/the_internet_journal_of_anesthesiology/volume_19_number_2/article/acute_fatal_fat_embolism_syndrome_in_bilateral_total_knee_arthroplasty_a_review_of_the_fat_embolism_syndrome.html

  15. Treatment Prophylaxis • Immobilization and early internal fixation of fracture • High doses of corticosteroids Medical • Self limiting disease. Support treatment for cardiovascular and respiratory issues • Maintenance of intravascular volume • Albumin is recommended • Adequate analgesia • Heparin

  16. Risk Factors

  17. Prognosis • Most death contributed to pulmonary dysfunction • Hard to determine exact mortality rate • Estimated less than 10%

  18. House M.D Clip Pulmonary Dysfunction • Respiratory Failure and ARDS (tachypnea, dyspnea, crackles, cyanosis) • Hypoxemia • systemic arterial hypotension, a decrease in cardiac output, and arrhythmias

  19. Sources Altaf Hussain: “A Fatal Fat Embolism.” The Internet Journal of Anesthesiology, 2004. Volume 8 Number 2. Fabian T. “Unraveling the fat embolism syndrome”. N Engl J Med 1993;329:961–63 U. Galway, J. E. Tetzlaff & R. Helfand : “Acute Fatal Fat Embolism Syndrome In Bilateral Total Knee Arthroplasty – A Review Of The Fat Embolism Syndrome”. The Internet Journal of Anesthesiology. 2009 Volume 19 Number 2 Latif, A., Bashir, A., Aurangzeb. "Fat Embolism and Fat Embolism Syndrome; Management Trends." Professional Med J 15.4 (2008): 407-413.

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