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Fat Embolism Workup

  • Author: Constantine S Bulauitan, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
 
Updated: Apr 06, 2015
 

Laboratory Studies

An otherwise unexplained increase in pulmonary shunt fraction alveolar-to-arterial oxygen tension difference, especially if it occurs within 24-48 hours of a sentinel event associated with fat embolism syndrome (FES), is strongly suggestive of the syndrome. Thrombocytopenia, anemia, and hypofibrinogenemia are indicative of FES; however, they are nonspecific.

Urinary fat stains are not considered to be sensitive or specific enough for diagnosing FES or for determining the risk of it. Fat globules in the urine are common after trauma.[22]

Preliminary investigations of the cytology of pulmonary capillary blood obtained from a wedged pulmonary artery catheter revealed fat globules in patients with FES and showed that this method may be beneficial in early detection of patients at risk.

In the future, genotyping for polymorphisms associated with increased susceptibility to inflammatory stimuli may help identify those at risk for FES. Specific antibody therapy targeting inflammatory molecules has not been useful.

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Radiography and Computed Tomography

Serial chest radiographs reveal increasing diffuse bilateral pulmonary infiltrates within 24-48 hours of the onset of clinical findings.

Findings from noncontrast computed tomography (CT) of the head performed because of alterations in mental status may be normal or may reveal diffuse white-matter petechial hemorrhages consistent with microvascular injury.

Because the embolic particles are lodged in the capillary beds, helical CT findings may be normal. Parenchymal changes consistent with lung contusion, acute lung injury, or acute respiratory distress syndrome (ARDS) may be evident. Nodular or ground-glass opacities in the setting of trauma suggest fat embolism.[5]

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Ultrasonography

In a small case study, five patients with trauma were monitored with intracranial Doppler ultrasonography, two during intraoperative nailing of long-bone fractures.[6] Cerebral microembolic signals were detected as long as 4 days after injury.

Transesophageal echocardiography (TEE) may be of use in evaluating the intraoperative release of marrow contents into the bloodstream during intramedullary reaming and nailing. The density of the echogenic material passing through the right side of the heart correlates with the degree of reduction in arterial oxygen saturation.

Repeated showers of emboli on TEE have been noted to increase right heart and pulmonary artery pressures. Embolization of marrow contents through a patent foramen ovale also has been noted. However, evidence of embolization obtained by means of TEE is not correlated with the actual development of FES.

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Bronchoalveolar Lavage With Staining for Fat

Bronchoalveolar lavage (BAL) specimens have been evaluated in trauma patients and sickle-cell patients with acute chest syndrome, and the results have been mixed.[7, 8]

Lipid inclusions commonly appear in patients with traumatic and nontraumatic respiratory failure; the standard cutoff in the BAL studies—5% fat-containing macrophages—results in a low specificity for the test. To improve specificity, some authors suggest raising the cutoff to 30%. At present, using BAL to aid in the diagnosis of FES or to predict its likelihood is controversial.

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Other Studies

Scant data exist regarding magnetic resonance imaging (MRI) findings in patients with FES; however, in one small patient group, multiple nonconfluent, hyperintense lesions were seen on proton-density– and T2-weighted images.[9]

Nuclear ventilation-perfusion imaging of the lungs may be performed when pulmonary embolism is suspected. The findings from this scan may be normal or may demonstrate subsegmental perfusion defects.

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Contributor Information and Disclosures
Author

Constantine S Bulauitan, MD Surgical Critical Care Fellow, Division of Acute Care Surgery, Rutgers Biomedical and Health Sciences, Rutgers Robert Wood Johnson Medical School

Constantine S Bulauitan, MD is a member of the following medical societies: American College of Surgeons, Society of Critical Care Medicine, Philippine Medical Association of America, World Surgical Foundation

Disclosure: Nothing to disclose.

Coauthor(s)

Rajan Gupta, MD, FACS, FCCP Associate Professor of Surgery, Chief, Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School

Rajan Gupta, MD, FACS, FCCP is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, Association for Academic Surgery, New Hampshire Medical Society, Shock Society, Society of Critical Care Medicine, Eastern Association for the Surgery of Trauma, European Society for Trauma and Emergency Surgery, Western Trauma Association, International Society of Surgery, International Association for Trauma Surgery and Intensive Care, New England Surgical Society

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Society for Vascular Surgery, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, Pacific Coast Surgical Association, Western Vascular Society

Disclosure: Nothing to disclose.

Acknowledgements

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.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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. 1987 Mar. 27(3):309-11. [Medline].

  2. 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. 1996 May. 153(5):1691-6. [Medline].

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

  4. Metting Z, Rödiger LA, Regtien JG, van der Naalt J. Delayed coma in head injury: consider cerebral fat embolism. Clin Neurol Neurosurg. 2009 Sep. 111(7):597-600. [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. Forteza AM, Koch S, Romano JG, et al. Transcranial doppler detection of fat emboli. Stroke. 1999 Dec. 30(12):2687-91. [Medline].

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

  8. 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. 1995 Dec. 21(12):973-80. [Medline].

  9. 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].

  10. Wong MW, Tsui HF, Yung SH, Chan KM, Cheng JC. Continuous pulse oximeter monitoring for inapparent hypoxemia after long bone fractures. J Trauma. 2004 Feb. 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. 1978 Sep. 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. 1990 May. 37(4 Pt 2):S130. [Medline].

  13. Tsitsikas DA, Gallinella G, Patel S, Seligman H, Greaves P, Amos RJ. Bone marrow necrosis and fat embolism syndrome in sickle cell disease: increased susceptibility of patients with non-SS genotypes and a possible association with human parvovirus B19 infection. Blood Rev. 2014 Jan. 28(1):23-30. [Medline].

  14. Fulde GW, Harrison P. Fat embolism--a review. Arch Emerg Med. 1991 Dec. 8(4):233-9. [Medline]. [Full Text].

  15. Mellor A, Soni N. Fat embolism. Anaesthesia. 2001 Feb. 56(2):145-54. [Medline].

  16. Allardyce DB, Meek RN, Woodruff B, Cassim MM, Ellis D. Increasing our knowledge of the pathogenesis of fat embolism: a prospective study of 43 patients with fractured femoral shafts. J Trauma. 1974 Nov. 14(11):955-62. [Medline].

  17. Meyer N, Pennington WT, Dewitt D, Schmeling GJ. Isolated cerebral fat emboli syndrome in multiply injured patients: a review of three cases and the literature. J Trauma. 2007 Dec. 63(6):1395-402. [Medline].

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

  19. Broe PJ, Toung TJ, Margolis S, Permutt S, Cameron JL. Pulmonary injury caused by free fatty acid: evaluation of steroid and albumin therapy. Surgery. 1981 May. 89(5):582-7. [Medline].

  20. Habashi NM, Andrews PL, Scalea TM. Therapeutic aspects of fat embolism syndrome. Injury. 2006 Oct. 37 Suppl 4:S68-73. [Medline].

  21. Kellogg RG, Fontes RB, Lopes DK. Massive cerebral involvement in fat embolism syndrome and intracranial pressure management. J Neurosurg. 2013 Nov. 119(5):1263-70. [Medline].

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

  23. Palmovic V, McCarroll JR. Fat embolism in trauma. Arch Pathol. 1965 Dec. 80(6):630-5. [Medline].

  24. Gurd AR, Wilson RI. The fat embolism syndrome. J Bone Joint Surg Br. 1974 Aug. 56B(3):408-16. [Medline].

  25. Shier MR, Wilson RF, James RE, Riddle J, Mammen EF, Pedersen HE. Fat embolism prophylaxis: a study of four treatment modalities. J Trauma. 1977 Aug. 17(8):621-9. [Medline].

  26. Bederman SS, Bhandari M, McKee MD, Schemitsch EH. Do corticosteroids reduce the risk of fat embolism syndrome in patients with long-bone fractures? A meta-analysis. Can J Surg. 2009 Oct. 52(5):386-93. [Medline]. [Full Text].

  27. White T, Petrisor BA, Bhandari M. Prevention of fat embolism syndrome. Injury. 2006 Oct. 37 Suppl 4:S59-67. [Medline].

 
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Hematoxylin-eosin stain of section of lungs showing blood vessel with fibrinoid material and optical empty space indicative of presence of lipid dissolved during staining process. This 55-year-old woman died of massive fat embolism after developing pancreatitis due to endoscopic retrograde cholangiopancreatography. Image courtesy of Wikimedia Commons. Originally published in Kanen BL, Loffeld RJLF. Pancreatitis with an unusual fatal complication following endoscopic retrograde cholangiopancreaticography: a case report. Journal of Medical Case Reports. 2008;2:215.
Frozen section of lung stained with oil red O showing multiple orange red fat globules of varying sizes in septal vasculature. Image courtesy of Dr AVC Rao, Senior Lecturer in Pathology, The University of the West Indies at St Augustine, Trinidad and Tobago. Originally published in Journal of Orthopaedics (http://www.jortho.org/2008/5/4/e8/).
 
 
 
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