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Fat embolism syndrome

Author
Gerald L Weinhouse, MD
Section Editor
Polly E Parsons, MD
Deputy Editor
Geraldine Finlay, MD

INTRODUCTION

Fat embolism syndrome (FES) is a rare syndrome that, when severe, is associated with respiratory failure, neurocognitive deficit, and death. It remains a diagnostic challenge for clinicians, but prompt recognition is important so that supportive therapy can be instituted early.

The pathogenesis and etiology, clinical presentation and diagnosis, prevention, treatment, and outcomes of FES are reviewed here. Other embolism syndromes are discussed separately. (See "Overview of acute pulmonary embolism in adults" and "Amniotic fluid embolism syndrome" and "Pulmonary tumor embolism and lymphangitic carcinomatosis in adults: Diagnostic evaluation and management" and "Air embolism".)

DEFINITION

Fat embolism is defined by the presence of fat globules in the pulmonary circulation. The term fat embolism syndrome (FES) refers to the clinical syndrome that follows an identifiable insult which releases fat into the circulation, resulting in pulmonary and systemic symptoms. (See 'Epidemiology and etiology' below and 'Clinical presentation' below and 'Diagnosis' below.)

EPIDEMIOLOGY AND ETIOLOGY

Fat embolism syndrome (FES) is a rare clinical syndrome that can complicate a wide variety of clinical conditions (table 1), particularly those where fat is manipulated. Almost all cases of FES are due to long bone and pelvic fractures (bone marrow contains a high content of fat). However, some cases are associated with trauma in the absence of orthopedic fractures and rare cases are nontrauma-related.

Orthopedic fractures or trauma — Rates of FES in orthopedic trauma patients varies from <1 percent to >30 percent, the wide range likely reflecting study population heterogeneity and a lack of standardization for diagnostic criteria. FES is most commonly associated with long bone (especially the femur) and pelvic fractures and less commonly with fractures of other marrow-containing bones (eg, ribs) (table 1) [1-3]. It is more frequent in closed fractures than open fractures. FES is more common in men than in women and its incidence is highest in those between 10 and 40 years, likely reflecting the incidence of trauma in this age group [2,4].

                            

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Literature review current through: Jan 2017. | This topic last updated: Tue Jan 17 00:00:00 GMT 2017.
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References
Top
  1. Mellor A, Soni N. Fat embolism. Anaesthesia 2001; 56:145.
  2. Stein PD, Yaekoub AY, Matta F, Kleerekoper M. Fat embolism syndrome. Am J Med Sci 2008; 336:472.
  3. Akhtar S. Fat embolism. Anesthesiol Clin 2009; 27:533.
  4. Eriksson EA, Pellegrini DC, Vanderkolk WE, et al. Incidence of pulmonary fat embolism at autopsy: an undiagnosed epidemic. J Trauma 2011; 71:312.
  5. Johnson MJ, Lucas GL. Fat embolism syndrome. Orthopedics 1996; 19:41.
  6. Ahmadzai H, Campbell S, Archis C, Clark WA. Fat embolism syndrome following percutaneous vertebroplasty: a case report. Spine J 2014; 14:e1.
  7. Al-Shaer DS, Ayoub O, Ahamed NA, et al. Cerebral fat embolism syndrome following total knee replacement causing a devastating neurocognitive sequelae. Neurosciences (Riyadh) 2016; 21:271.
  8. Hjort M, Hoegberg LC, Almind M, Jansen T. Subacute fat-embolism-like syndrome following high-volume intramuscular and accidental intravascular injection of mineral oil. Clin Toxicol (Phila) 2015; 53:230.
  9. Baselga J, Reich L, Doherty M, Gulati S. Fat embolism syndrome following bone marrow harvesting. Bone Marrow Transplant 1991; 7:485.
  10. de Lima E Souza R, Apgaua BT, Milhomens JD, et al. Severe fat embolism in perioperative abdominal liposuction and fat grafting. Braz J Anesthesiol 2016; 66:324.
  11. Mendoza-Morales RC, Camberos-Nava EV, Luna-Rosas A, et al. A fatal case of systemic fat embolism resulting from gluteal injections of vitamin e for cosmetic enhancement. Forensic Sci Int 2016; 259:e1.
  12. Jacob S, Courtwright A, El-Chemaly S, et al. Donor-acquired fat embolism syndrome after lung transplantation. Eur J Cardiothorac Surg 2016; 49:1344.
  13. Schrufer-Poland T, Singh P, Jodicke C, et al. Nontraumatic Fat Embolism Found Following Maternal Death after Cesarean Delivery. AJP Rep 2015; 5:e1.
  14. Jones JP Jr. Fat embolism, intravascular coagulation, and osteonecrosis. Clin Orthop Relat Res 1993; :294.
  15. Vichinsky E, Williams R, Das M, et al. Pulmonary fat embolism: a distinct cause of severe acute chest syndrome in sickle cell anemia. Blood 1994; 83:3107.
  16. Schonfeld SA, Ploysongsang Y, DiLisio R, et al. Fat embolism prophylaxis with corticosteroids. A prospective study in high-risk patients. Ann Intern Med 1983; 99:438.
  17. Garza JA. Massive fat and necrotic bone marrow embolization in a previously undiagnosed patient with sickle cell disease. Am J Forensic Med Pathol 1990; 11:83.
  18. Walsh K, Alexander G. Alcoholic liver disease. Postgrad Med J 2000; 76:280.
  19. Schulz F, Trübner K, Hildebrand E. Fatal fat embolism in acute hepatic necrosis with associated fatty liver. Am J Forensic Med Pathol 1996; 17:264.
  20. Sinha A, Olah KS. Acute fatty liver of pregnancy: an unusual presentation. J Obstet Gynaecol 2005; 25:60.
  21. Levine M, Skolnik AB, Ruha AM, et al. Complications following antidotal use of intravenous lipid emulsion therapy. J Med Toxicol 2014; 10:10.
  22. Kontzialis M, Lee VH, Jhaveri MD. TIA Due to Cerebral Fat Embolism Following Lipid-Based Sonographic Contrast Agent Injection. Eur Neurol 2016; 75:169.
  23. Celikkanat S, Hamcan S, Bozlar U, Tasar M. Epipericardial fat necrosis clinically mimicking pulmonary embolism: computed tomographic angiography findings. Am J Emerg Med 2016; 34:2056.e5.
  24. Celik SU, Kocaay AF, Sevim Y, et al. Renal Angiomyolipoma With Caval Extension and Pulmonary Fat Embolism: A Case Report. Medicine (Baltimore) 2015; 94:e1078.
  25. Gangaraju R, Reddy VV, Marques MB. Fat Embolism Syndrome Secondary to Bone Marrow Necrosis in Patients with Hemoglobinopathies. South Med J 2016; 109:549.
  26. Russell M, Storck A, Ainslie M. Acute respiratory distress following intravenous injection of an oil-steroid solution. Can Respir J 2011; 18:e59.
  27. Karayel F, Arican N, Kavas G, et al. Maternal death due to non-traumatic fat embolism. J Forensic Sci 2005; 50:1201.
  28. Pell AC, Hughes D, Keating J, et al. Brief report: fulminating fat embolism syndrome caused by paradoxical embolism through a patent foramen ovale. N Engl J Med 1993; 329:926.
  29. Takahashi S, Kitagawa H, Ishii T. Intraoperative pulmonary embolism during spinal instrumentation surgery. A prospective study using transoesophageal echocardiography. J Bone Joint Surg Br 2003; 85:90.
  30. Sulek CA, Davies LK, Enneking FK, et al. Cerebral microembolism diagnosed by transcranial Doppler during total knee arthroplasty: correlation with transesophageal echocardiography. Anesthesiology 1999; 91:672.
  31. Nixon JR, Brock-Utne JG. Free fatty acid and arterial oxygen changes following major injury: a correlation between hypoxemia and increased free fatty acid levels. J Trauma 1978; 18:23.
  32. Schnaid E, Lamprey JM, Viljoen MJ, et al. The early biochemical and hormonal profile of patients with long bone fractures at risk of fat embolism syndrome. J Trauma 1987; 27:309.
  33. GLAS WW, GREKIN TD, MUSSELMAN MM. Fat embolism. Am J Surg 1953; 85:363.
  34. Hulman G. Pathogenesis of non-traumatic fat embolism. Lancet 1988; 1:1366.
  35. Kao SJ, Yeh DY, Chen HI. Clinical and pathological features of fat embolism with acute respiratory distress syndrome. Clin Sci (Lond) 2007; 113:279.
  36. Prakash S, Sen RK, Tripathy SK, et al. Role of interleukin-6 as an early marker of fat embolism syndrome: a clinical study. Clin Orthop Relat Res 2013; 471:2340.
  37. Carr JB, Hansen ST. Fulminant fat embolism. Orthopedics 1990; 13:258.
  38. Bulger EM, Smith DG, Maier RV, Jurkovich GJ. Fat embolism syndrome. A 10-year review. Arch Surg 1997; 132:435.
  39. King MB, Harmon KR. Unusual forms of pulmonary embolism. Clin Chest Med 1994; 15:561.
  40. Aggarwal R, Pal S, Soni KD, Gamangatti S. Massive cerebral fat embolism leading to brain death: A rare presentation. Indian J Crit Care Med 2015; 19:687.
  41. Jacobson DM, Terrence CF, Reinmuth OM. The neurologic manifestations of fat embolism. Neurology 1986; 36:847.
  42. Georgopoulos D, Bouros D. Fat embolism syndrome: clinical examination is still the preferable diagnostic method. Chest 2003; 123:982.
  43. Kaplan RP, Grant JN, Kaufman AJ. Dermatologic features of the fat embolism syndrome. Cutis 1986; 38:52.
  44. Gitin TA, Seidel T, Cera PJ, et al. Pulmonary microvascular fat: the significance? Crit Care Med 1993; 21:673.
  45. Umali, CB, Smith, EH. The chest radiographic examination. In: Intensive Care Medicine, Rippe, JM, Irwin, RS, Alpert, JS, Fink, MP (Eds), Little Brown, Boston 1991. p.596.
  46. Arakawa H, Kurihara Y, Nakajima Y. Pulmonary fat embolism syndrome: CT findings in six patients. J Comput Assist Tomogr 2000; 24:24.
  47. Malagari K, Economopoulos N, Stoupis C, et al. High-resolution CT findings in mild pulmonary fat embolism. Chest 2003; 123:1196.
  48. Nucifora G, Hysko F, Vit A, Vasciaveo A. Pulmonary fat embolism: common and unusual computed tomography findings. J Comput Assist Tomogr 2007; 31:806.
  49. Newbigin K, Souza CA, Torres C, et al. Fat embolism syndrome: State-of-the-art review focused on pulmonary imaging findings. Respir Med 2016; 113:93.
  50. Piolanti M, Dalpiaz G, Scaglione M, et al. Fat Embolism Syndrome: Lung Computed Tomography Findings in 18 Patients. J Comput Assist Tomogr 2016; 40:335.
  51. Newbigin K, Souza CA, Armstrong M, et al. Fat embolism syndrome: Do the CT findings correlate with clinical course and severity of symptoms? A clinical-radiological study. Eur J Radiol 2016; 85:422.
  52. Park HM, Ducret RP, Brindley DC. Pulmonary imaging in fat embolism syndrome. Clin Nucl Med 1986; 11:521.
  53. Kellogg RG, Fontes RB, Lopes DK. Massive cerebral involvement in fat embolism syndrome and intracranial pressure management. J Neurosurg 2013; 119:1263.
  54. Takahashi M, Suzuki R, Osakabe Y, et al. Magnetic resonance imaging findings in cerebral fat embolism: correlation with clinical manifestations. J Trauma 1999; 46:324.
  55. Ryu CW, Lee DH, Kim TK, et al. Cerebral fat embolism: diffusion-weighted magnetic resonance imaging findings. Acta Radiol 2005; 46:528.
  56. Sato HK, Kowacs PA, Dalmau J, Santos PS. Fat embolism showing restriction on diffusion sequence in brain magnetic resonance imaging. Arq Neuropsiquiatr 2016; 74:597.
  57. Han YT, Tang J, Gao ZQ, Hu HT. Clinical Features and Neuroimaging Findings in Patients with Cerebral Fat Embolism. Chin Med J (Engl) 2016; 129:874.
  58. Kuo KH, Pan YJ, Lai YJ, et al. Dynamic MR imaging patterns of cerebral fat embolism: a systematic review with illustrative cases. AJNR Am J Neuroradiol 2014; 35:1052.
  59. Shaikh N. Emergency management of fat embolism syndrome. J Emerg Trauma Shock 2009; 2:29.
  60. Gurd, AR. Fat embolism: An aid to diagnosis. J Bone Joint Surg 1970; 52B:732.
  61. Godeau B, Schaeffer A, Bachir D, et al. 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; 153:1691.
  62. Chastre J, Fagon JY, Soler P, et al. Bronchoalveolar lavage for rapid diagnosis of the fat embolism syndrome in trauma patients. Ann Intern Med 1990; 113:583.
  63. Karagiorga G, Nakos G, Galiatsou E, Lekka ME. Biochemical parameters of bronchoalveolar lavage fluid in fat embolism. Intensive Care Med 2006; 32:116.
  64. Mimoz O, Edouard A, Beydon L, et al. Contribution of bronchoalveolar lavage to the diagnosis of posttraumatic pulmonary fat embolism. Intensive Care Med 1995; 21:973.
  65. Lindeque BG, Schoeman HS, Dommisse GF, et al. Fat embolism and the fat embolism syndrome. A double-blind therapeutic study. J Bone Joint Surg Br 1987; 69:128.
  66. Sarkar S, Mandal K, Bhattacharya P. Successful management of massive intraoperative pulmonary fat embolism with percutaneous cardiopulmonary support. Indian J Crit Care Med 2008; 12:136.
  67. Webb DP, McKamie WA, Pietsch JB. Resuscitation of fat embolism syndrome with extracorporeal membrane oxygenation. J Extra Corpor Technol 2004; 36:368.
  68. Kubota T, Ebina T, Tonosaki M, et al. Rapid improvement of respiratory symptoms associated with fat embolism by high-dose methylpredonisolone: a case report. J Anesth 2003; 17:186.
  69. Fischer JE, Turner RH, Herndon JH, Riseborough EJ. Massive steroid therapy in severe fat embolism. Surg Gynecol Obstet 1971; 132:667.
  70. Ashbaugh DG, Petty TL. The use of corticosteroids in the treatment of respiratory failure associated with massive fat embolism. Surg Gynecol Obstet 1966; 123:493.
  71. Sethi D, Kajal S, Saxena A. Neuroimaging findings in a case of cerebral fat embolism syndrome with delayed recovery. Indian J Crit Care Med 2015; 19:674.
  72. Fulde GW, Harrison P. Fat embolism--a review. Arch Emerg Med 1991; 8:233.
  73. 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; 52:386.
  74. Riska EB, Myllynen P. Fat embolism in patients with multiple injuries. J Trauma 1982; 22:891.
  75. Pitto RP, Schramm M, Hohmann D, Kössler M. Relevance of the drainage along the linea aspera for the reduction of fat embolism during cemented total hip arthroplasty. A prospective, randomized clinical trial. Arch Orthop Trauma Surg 1999; 119:146.
  76. Pitto RP, Koessler M, Kuehle JW. Comparison of fixation of the femoral component without cement and fixation with use of a bone-vacuum cementing technique for the prevention of fat embolism during total hip arthroplasty. A prospective, randomized clinical trial. J Bone Joint Surg Am 1999; 81:831.
  77. Kröpfl A, Davies J, Berger U, et al. Intramedullary pressure and bone marrow fat extravasation in reamed and unreamed femoral nailing. J Orthop Res 1999; 17:261.
  78. Kim YH, Oh SW, Kim JS. Prevalence of fat embolism following bilateral simultaneous and unilateral total hip arthroplasty performed with or without cement : a prospective, randomized clinical study. J Bone Joint Surg Am 2002; 84-A:1372.
  79. Pitto RP, Hamer H, Fabiani R, et al. Prophylaxis against fat and bone-marrow embolism during total hip arthroplasty reduces the incidence of postoperative deep-vein thrombosis: a controlled, randomized clinical trial. J Bone Joint Surg Am 2002; 84-A:39.
  80. Alho A, Saikku K, Eerola P, et al. Corticosteroids in patients with a high risk of fat embolism syndrome. Surg Gynecol Obstet 1978; 147:358.
  81. Kallenbach J, Lewis M, Zaltzman M, et al. 'Low-dose' corticosteroid prophylaxis against fat embolism. J Trauma 1987; 27:1173.
  82. Silva DF, Carmona CV, Calderan TR, et al. The use of corticosteroid for the prophylaxis of fat embolism syndrome in patients with long bone fracture. Rev Col Bras Cir 2013; 40:423.
  83. Sen RK, Tripathy SK, Krishnan V. Role of corticosteroid as a prophylactic measure in fat embolism syndrome: a literature review. Musculoskelet Surg 2012; 96:1.
  84. Sen RK, Prakash S, Tripathy SK, et al. Inhalational Ciclesonide found beneficial in prevention of fat embolism syndrome and improvement of hypoxia in isolated skeletal trauma victims. Eur J Trauma Emerg Surg 2016.
  85. Kim CH, Chung DH, Yoo CG, et al. A case of acute pneumonitis induced by injection of silicone for colpoplasty. Respiration 2003; 70:104.
  86. Lai YF, Chao TY, Wong SL. Acute pneumonitis after subcutaneous injections of silicone for augmentation mammaplasty. Chest 1994; 106:1152.
  87. Purdy-Payne EK, Green J, Zenoni S, et al. A Serious Complication of Illicit Silicone Injections: Latent Silicone Embolization Syndrome after Incision and Drainage of Local Injection Site. Surg Infect (Larchmt) 2015; 16:473.
  88. Capan LM, Lardizabal S, Sinha K, et al. Acute pulmonary embolism during therapeutic arterial embolization with silicone fluids. Anesthesiology 1983; 58:569.
  89. Chung KY, Kim SH, Kwon IH, et al. Clinicopathologic review of pulmonary silicone embolism with special emphasis on the resultant histologic diversity in the lung--a review of five cases. Yonsei Med J 2002; 43:152.
  90. Schmid A, Tzur A, Leshko L, Krieger BP. Silicone embolism syndrome: a case report, review of the literature, and comparison with fat embolism syndrome. Chest 2005; 127:2276.