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Fat Embolism

Author: Lisa Kirkland, MD, FACP, CNSP, MSHA, Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; ANW Intensivists, Abbott Northwestern Hospital
Contributor Information and Disclosures

Updated: Aug 4, 2009

Introduction

Background

In 1862, Zenker first described fat embolism at autopsy. In 1873, von Bergmann clinically diagnosed fat embolism syndrome for the first time.

Pathophysiology

Two theories about fat embolism exist. First, the mechanical theory states that large fat droplets are released into the venous system. These droplets are deposited in the pulmonary capillary beds and travel through arteriovenous shunts to the brain. Microvascular lodging of droplets produces local ischemia and inflammation, with concomitant release of inflammatory mediators, platelet aggregation, and vasoactive amines.

Second, the biochemical theory states that hormonal changes caused by trauma and/or sepsis induce systemic release of free fatty acids as chylomicrons. Acute-phase reactants, such as C-reactive proteins, cause chylomicrons to coalesce and create the physiologic reactions described above. The biochemical theory helps explain nontraumatic forms of fat embolism syndrome.1

Haematoxylin and eosin stain of a section of the ...

Haematoxylin and eosin stain of a section of the lungs showing a blood vessel with fibrinoid material and an optical empty space indicative of the presence of lipid dissolved during the staining process. This 55-year-old woman died of massive fat embolism after developing pancreatitis due to endoscopic retrograde cholangiopancreaticography. Image source: Pancreatitis with an unusual fatal complication following endoscopic retrograde cholangiopancreaticography: a case report. Journal of Medical Case Reports. 2008;2:215.

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Haematoxylin and eosin stain of a section of the ...

Haematoxylin and eosin stain of a section of the lungs showing a blood vessel with fibrinoid material and an optical empty space indicative of the presence of lipid dissolved during the staining process. This 55-year-old woman died of massive fat embolism after developing pancreatitis due to endoscopic retrograde cholangiopancreaticography. Image source: Pancreatitis with an unusual fatal complication following endoscopic retrograde cholangiopancreaticography: a case report. Journal of Medical Case Reports. 2008;2:215.

Frequency

United States

Frequency is estimated to be 3-4%. Fat embolism is a clinical diagnosis. Many patients are likely to have a missed diagnosis because of subclinical illness or confounding injury or illness.

Mortality/Morbidity

The mortality rate of fat embolism is 10-20%. Patients with increased age, multiple underlying medical problems, and/or decreased physiologic reserves have worse outcomes than other patients.

Clinical

History

  • Trauma to long bone or pelvis, including orthopedic procedures
  • Parenteral lipid infusion
  • Recent corticosteroid administration

Physical

Respiratory symptoms, signs of radiologic disease; cerebral signs without other etiologies; and petechial rash are the major criteria. A pulse that is over 110 beats per minute, fever over 38.5 º C, retinal changes of fat globules or petechiae, renal dysfunction, jaundice, acute drop in hemoglobin and/or platelets, and elevated sedimentation rate are the minor criteria. One major and 4 minor criteria, plus fat microglobulinemia, must be present to formally diagnose fat embolism syndrome.

  • Cardiopulmonary
    • Early persistent tachycardia may herald the onset of the syndrome.
    • Patients become tachypneic, dyspneic, and hypoxic due to ventilation-perfusion abnormalities 12-72 hours after injury.
    • Patients become febrile with high-spiking temperatures.
  • Dermatologic
    • Alert clinicians may notice reddish-brown nonpalpable petechiae developing over the upper body, particularly in the axillae, within 24-36 hours of insult or injury. These petechiae occur in only 20-50% of patients and resolve quickly, but they are virtually diagnostic in the right clinical setting.
    • Subconjunctival and oral hemorrhages and petechiae also appear.
  • Neurologic
    • Central nervous system dysfunction initially manifests as agitated delirium but may progress to stupor, seizures, or coma and is frequently unresponsive to correction of hypoxia.2
    • Retinal hemorrhages with intra-arterial fat globules are visible upon funduscopic examination.

Causes

  • Blunt trauma (associated with 90% of all cases)
  • Acute pancreatitis
  • Diabetes mellitus
  • Burns
  • Joint reconstruction
  • Liposuction
  • Cardiopulmonary bypass
  • Decompression sickness
  • Parenteral lipid infusion
  • Sickle cell crisis3,4
  • Pathologic fractures

More on Fat Embolism

Overview: Fat Embolism
Differential Diagnoses & Workup: Fat Embolism
Treatment & Medication: Fat Embolism
Follow-up: Fat Embolism
Multimedia: Fat Embolism
References
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References

  1. Schnaid E, Lamprey JM, Viljoen MJ, Joffe BI, Seftel HC. The early biochemical and hormonal profile of patients with long bone fractures at risk of fat embolism syndrome. J Trauma. Mar 1987;27(3):309-11. [Medline].

  2. Metting Z, Rödiger LA, Regtien JG, van der Naalt J. Delayed coma in head injury: consider cerebral fat embolism. Clin Neurol Neurosurg. Sep 2009;111(7):597-600. [Medline].

  3. Godeau B, Schaeffer A, Bachir D, Fleury-Feith J, Galacteros F, Verra F. Bronchoalveolar lavage in adult sickle cell patients with acute chest syndrome: value for diagnostic assessment of fat embolism. Am J Respir Crit Care Med. May 1996;153(5):1691-6. [Medline].

  4. Shapiro MP, Hayes JA. Fat embolism in sickle cell disease. Report of a case with brief review of the literature. Arch Intern Med. Jan 1984;144(1):181-2. [Medline].

  5. Gallardo X, CastanerE, Mata JM. Nodular pattern at Lung Computed Tomography in Fat Embolism Syndrome: A Helpful Finding. J Computer Assisted Tomography. 2006;30:254-7.

  6. Stoeger A, Daniaux M, Felber S, Stockhammer G, Aichner F, zur Nedden D. MRI findings in cerebral fat embolism. Eur Radiol. 1998;8(9):1590-3. [Medline].

  7. Forteza AM, Koch S, Romano JG, et al. Transcranial doppler detection of fat emboli. Stroke. Dec 1999;30(12):2687-91. [Medline].

  8. Vedrinne JM, Guillaume C, Gagnieu MC, Gratadour P, Fleuret C, Motin J. Bronchoalveolar lavage in trauma patients for diagnosis of fat embolism syndrome. Chest. Nov 1992;102(5):1323-7. [Medline].

  9. Mimoz O, Edouard A, Beydon L, Quillard J, Verra F, Fleury J. Contribution of bronchoalveolar lavage to the diagnosis of posttraumatic pulmonary fat embolism. Intensive Care Med. Dec 1995;21(12):973-80. [Medline].

  10. Wong MW, Tsui HF, Yung SH, Chan KM, Cheng JC. Continuous pulse oximeter monitoring for inapparent hypoxemia after long bone fractures. J Trauma. Feb 2004;56(2):356-62. [Medline].

  11. Alho A, Saikku K, Eerola P, Koskinen M, Hämäläinen M. Corticosteroids in patients with a high risk of fat embolism syndrome. Surg Gynecol Obstet. Sep 1978;147(3):358-62. [Medline].

  12. Byrick RJ, Mullen JB, Wong PY, Wigglesworth D, Kay JC. Corticosteroids do not inhibit acute pulmonary response to fat embolism. Can J Anaesth. May 1990;37(4 Pt 2):S130. [Medline].

  13. Bilgrami S, Hasson J, Tutschka PJ. Case 23-1998: fat embolism. N Engl J Med. Feb 4 1999;340(5):393-4. [Medline].

  14. Estebe JP, Malledant Y. Fat embolism after lipid emulsion infusion. Lancet. Mar 16 1991;337(8742):673. [Medline].

  15. Fabian TC. Unravelling the fat embolism syndrome. N Engl J Med. Sep 23 1993;329(13):961-3. [Medline].

  16. Fabian TC, Hoots AV, Stanford DS, Patterson CR, Mangiante EC. Fat embolism syndrome: prospective evaluation in 92 fracture patients. Crit Care Med. Jan 1990;18(1):42-6. [Medline].

  17. Habashi NM, Andrews PL. Therapeutic Aspects of Fat Embolism Syndrome. Injury. 2006;37(Supplem 4):S68-73.

  18. Hofmann S, Hopf R, Huemer G, Kratochwill C, Koller-Strametz J, Schlag G. [Modified surgical technique for reduction of bone marrow spilling in cement-free hip endoprosthesis]. Orthopade. Apr 1995;24(2):130-7. [Medline].

  19. Kallenbach J, Lewis M, Zaltzman M, Feldman C, Orford A, Zwi S. 'Low-dose' corticosteroid prophylaxis against fat embolism. J Trauma. Oct 1987;27(10):1173-6. [Medline].

  20. Reider E, Sherman Y, Weiss Y, Liebergall M, Pizov R. Alveolar macrophages fat stain in early diagnosis of fat embolism syndrome. Isr J Med Sci. Oct 1997;33(10):654-8. [Medline].

  21. Schonfeld SA, Ploysongsang Y, DiLisio R, Crissman JD, Miller E, Hammerschmidt DE. Fat embolism prophylaxis with corticosteroids. A prospective study in high-risk patients. Ann Intern Med. Oct 1983;99(4):438-43. [Medline].

  22. Scully RE, Mark EJ, McNeely WF. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 23-1998. Tachypnea, changed mental status, and pancytopenia in an elderly man with treated lymphoma. N Engl J Med. Jul 23 1998;339(4):254-61. [Medline].

  23. Teng QS, Li G, Zhang BX, Zhu XH, Ma CX. Experimental study of early diagnosis and treatment of fat embolism syndrome. J Orthop Trauma. Jun 1995;9(3):183-9. [Medline].

  24. White T, Petrisor BA, Bhandar M. Prevention of Fat Embolism Syndrome. Injury. 2006;37(Supplem 1):S59-67.

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Further Reading

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Keywords

fat embolism syndrome, FES, fat emboli, fat embolus, fat droplet in venous system, blunt trauma, fracture complication, blunt trauma complication, altered mental status

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Contributor Information and Disclosures

Author

Lisa Kirkland, MD, FACP, CNSP, MSHA, Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; ANW Intensivists, Abbott Northwestern Hospital
Lisa Kirkland, MD, FACP, CNSP, MSHA is a member of the following medical societies: American College of Physicians, Society of Critical Care Medicine, and Society of Hospital Medicine
Disclosure: Nothing to disclose.

Medical Editor

Richard M Stillman, MD, FACS, Honorary Medical Staff, Northwest Medical Center; Former Chief of Staff and Medical Director, Wound Healing Center, Department of Surgery, Northwest Medical Center
Richard M Stillman, MD, FACS is a member of the following medical societies: American College of Angiology, American College of Surgeons, Association for Academic Surgery, and Society of University Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Travis J Phifer, MD, Chief, Division of Vascular Surgery, Professor, Department of Surgery and Radiology, Louisiana State University Health Sciences Center in Shreveport
Travis J Phifer, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Society for Academic Emergency Medicine, Society for Vascular Surgery, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

 
 
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