How to Save a Life From Macroscopic Fat Embolism: A Narrative Review of Treatment Options

Fat embolism: the hidden murder for trauma patients!

INTRODUCTION

fat embolism syndrome (FES) is an acute respiratory disorder that occurs when an inflammatory response causes the embolization of fat and marrow particles into the bloodstream. The exact incidence of FES is not well defined due to the difficulty of diagnosis. FES is mostly associated with isolated long bone trauma, and it is usually misdiagnosed in other trauma cases. The scope of this study was to identify and search the current literature for cases of FES in nonorthopedic trauma patients with the aim of defining the etiology, incidence, and main clinical manifestations.

METHODS

we perform a literature search via the PubMed journal to find, summarize, and incorporate reports of fat embolisms in patients presenting with non-orthopedic trauma.

RESULTS

the final literature search yielded 23 papers of patients presenting with fat embolism/FES due to non-orthopedic trauma. The presentation and etiology of these fat embolisms is varied and complex, differing from patient to patient. In this review, we highlight the importance of maintaining a clinical suspicion of FES within the trauma and critical care community.

CONCLUSION

to help trauma surgeons and clinicians identify FES cases in trauma patients who do not present with long bone fracture, we also present the main clinical signs of FES as well as the possible treatment and prevention options.

Nontrombotic Pulmonary Embolism: Different Etiology, Same Significant Consequences

Nontrombotic pulmonary embolism represents the embolization of different types of materials (cells, organisms, gas, foreign material) into pulmonary circulation. The disease is uncommon, and clinical presentation together with laboratory findings are nonspecific. Its pathology is usually misdiagnosed based on imaging findings as pulmonary thromboembolism, but the correct diagnosis is essential because different therapeutic approaches are required. In this context, knowledge of the risk factors associated with nontrombotic pulmonary embolism and specific clinical symptoms is fundamental. Our objective was to discuss the specific features of the most common etiologies of nontrombotic pulmonary embolism, gas, fat, amniotic fluid, sepsis and tumors, to provide assistance for a rapid and correct diagnosis. Because the most common etiologies are iatrogenic, knowledge of the risk factors could be an important tool for prevention or rapid treatment if the disease develops during different procedures. The diagnosis of nontrombotic pulmonary embolisms represent a laborious challenge, and endeavors should be made to prevent development and increase awareness of this disease.

Fat Embolism Syndrome and in-Hospital Mortality Rates According to Patient Age: A Large Nationwide Retrospective Study

Introduction

Fat embolism syndrome (FES) is a rare life-threatening condition that can develop after traumatic orthopedic injuries. Controversy remains concerning the epidemiology in the elderly population. Therefore, this study aims to report FES related to in-hospital mortality stratified by age.

Methods

A retrospective trauma cohort study was conducted using data from the National Trauma Data Bank (NTDB) from 2007 to 2014. All FES cases were included in the study with the diagnosis of FES (ICD9 958.1). Death on arrival cases were excluded. Patients were stratified by age cohort: less than 40 (G1), 40–64 (G2), and greater than 65 (G3) years of age. The primary outcome evaluated was in-hospital mortality. Multivariable regression models were performed to adjust for potential confounders.

Results

Between 2007 and 2014, 451 people from a total of 5,836,499 trauma patients in the NTDB met the inclusion criteria. The incidence rate was 8 out of 100,000. The inpatient mortality rate was 11.8% for all subjects with the highest mortality rate of 17.6% in patients over 65. Multivariable analyses demonstrated that age greater than 65 years was an independent predictor of mortality (aOR 24.16, 95% CI 3.73, 156.59, p=0.001), despite higher incidence and injury severity of FES among patients less than 40. No significant association with length of hospital stay, length of intensive unit care, or length of ventilation use was found between the groups. Subgroup analysis of the elderly population also showed a higher mortality rate for FES in femoral neck fracture patients (18%) than other femoral fractures (14%).

Conclusion

In this retrospective cohort analysis, old age (≥ 65 years) was found to be an independent risk factor for in-hospital mortality among fat embolism syndrome patients. Elderly patients specifically with femoral neck fractures should be monitored for the development of FES.

Fatal Fulminant Fat Embolism Syndrome in Adult Spine Deformity Surgery: A Case Report

CASE

A 68-year-old woman was scheduled to undergo elective correction of coronal spinal malalignment after a previous lumbar instrumented fusion. In the final stages of the operation, the patient became hemodynamically unstable. Her systemic condition worsened subsequently, leading to cardiac arrest followed by unsuccessful resuscitation. An autopsy revealed a massive fat embolism in the lungs.

CONCLUSIONS

The diagnosis of fat embolism syndrome (FES) is clinical, and treatment is supportive, with no clinical or investigative criteria that can facilitate diagnosis in a patient under general anesthesia. This is the first description of FES in adult spinal deformity surgery.

Fat Embolism After Autologous Facial Fat Grafting

BACKGROUND

Autologous facial fat grafting has gained popularity in recent years and is considered to be safe. This paper presents the case of a patient who died due to massive cerebral microfat embolism after facial fat grafting.

OBJECTIVES

The aim of this study was to raise awareness and provide more evidence on the prevention and treatment of this potentially lethal complication of facial fat grafting.

METHODS

A detailed report was made of the case. Two online databases were searched for similar cases of facial fat embolism resulting in neurologic and/or visual symptoms. Thereafter a literature search was conducted to verify the etiology, current treatment options, and preventive measures.

RESULTS

Forty-nine cases with similar events were found in the literature. The most common injected area was the glabella (36.1%), and an average of 16.7 mL fat was injected. The main complications were visual impairment, with 88.5% of cases resulting in permanent monocular blindness, and neurologic symptoms, some of which never fully recovered. Including the present patient, 7 cases were fatal. Fat embolism can occur in the veins and arteries of the face. Two possible pathways for fat embolism exist: the macroscopic, mechanical pathway with immediate signs, and the microscopic, biochemical pathway with delayed symptoms. Mechanical embolectomy and corticosteroids are suggested treatment options but evidence for their efficacy is lacking. Several different preventive measures are described.

CONCLUSIONS

Although facial fat grafting is considered a safe procedure, one should be aware of the risk of fat embolism. Underreporting of this adverse event is likely. With no effective treatment and often detrimental outcomes, preventive measures are of utmost importance to improve patient safety.

LEVEL OF EVIDENCE: 4

Incidence of Fat Embolism Syndrome in Femur Fractures and Its Associated Risk Factors over Time-A Systematic Review

BACKGROUND

Fat embolism (FE) continues to be mentioned as a substantial complication following acute femur fractures. The aim of this systematic review was to test the hypotheses that the incidence of fat embolism syndrome (FES) has decreased since its description and that specific injury patterns predispose to its development.

MATERIALS AND METHODS

Data Sources: MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases were searched for articles from 1 January 1960 to 31 December 2019.

STUDY SELECTION

Original articles that provide information on the rate of FES, associated femoral injury patterns, and therapeutic and diagnostic recommendations were included.

DATA EXTRACTION

Two authors independently extracted data using a predesigned form.

STATISTICS

Three different periods were separated based on the diagnostic and treatment changes: Group 1: 1 January 1960-12 December 1979, Group 2: 1 January 1980-1 December 1999, and Group 3: 1 January 2000-31 December 2019, chi-square test, χ² test for group comparisons of categorical variables, p-value < 0.05.

RESULTS

Fifteen articles were included (n = 3095 patients). The incidence of FES decreased over time (Group 1: 7.9%, Group 2: 4.8%, and Group 3: 1.7% (p < 0.001)). FES rate according to injury pattern: unilateral high-energy fractures (2.9%) had a significantly lower FES rate than pathological fractures (3.3%) and bilateral high-energy fractures (4.6%) (p < 0.001).

CONCLUSIONS

There has been a significant decrease in the incidence of FES over time. The injury pattern impacts the frequency of FES. The diagnostic and therapeutic approach to FES remains highly heterogenic to this day.

Personal Strategy to Avoid Fat Embolism During Fat Grafting: Brisk Withdrawal of Cannula While Injection

INTRODUCTION

Complications of fat grafting by means of injection may lead to unwanted passage of substrate into vessel lumens resulting in catastrophic complications. Likewise, a similar trend of complications is observed with non-autologous fillers regardless of an almost generalized use of blunt cannulas, the latter being implicated in the majority of serious vascular complications of hyaluronic acid injection. This report is the product of investigation to review all cases that underwent an original technique of fat injection: "The smart fat injection" during the cannula's brisk withdrawal technique. The aim of this research was to document the safety of this technique by searching if fat embolism had occurred and if yes, its incidence in this group of fat injection surgeries.

METHOD

This retrospective review included 3039 patients who underwent the smart fat injection at the facial or corporeal level between 2001 and 2019. The study focused on the search for complications linked to fat yet also cruorical embolism, as the latter may resemble the clinical symptoms of fat embolism.

RESULTS

The assessment of the 3039 patients who underwent the smart fat injection during cannula's brisk withdrawal, resulted in none presenting clinically detectable fat or a cruorical embolism.

CONCLUSION

This report documents the safety of the smart fat injection developed over a period of 22 years. It further explains the rationale of the technique for avoiding fat embolism while simultaneously enhancing fat take. This technique should not be implemented without appropriate in vitro training.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .