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Fat embolism and postoperative coagulopathy

Hertfordshire, Uk

To the Editor:

I was interested to read the article¹ and accompanying editorial² regarding fat embolism and postoperative coagulopathy.

Byrick points out that "even after cardiac arrest and resuscitation, such an impressive coagulopathy, leading to shock and death is exceedingly rare".

I recently reported a case of the fat embolism syndrome³ in an 18-yr-old girl who had sustained a minimally displaced oblique fracture through the mid-shaft of her left tibia and fibula. In this case only very gentle, closed manipulation (performed within 24 hr of the accident) was required to bring the bones to a suitable alignment. Nonetheless, she developed disseminated intravascular coagulation, multi-organ dysfunction syndrome, and refractory hypoxemia, dying approximately six days and a half after the initial injury.

I agree with Byrick's comment that ‘intravascular fat may only be a marker for the intravasation of marrow products during cemented arthroplasty': this then begs the question why did such a common event⁴ have such devastating consequences in these two particular patients? Does it have anything to do with an abnormal and overwhelming inflammatory response? If so, who (and why) are certain people liable to such reactions?

In the case I described the only medical history of note was that of resolved but, at the time, debilitating myalgic encephalomyelitis. Was this another manifestation of an abnormally reactive immune/inflammatory system? If the immune system is involved how can we identify such patients, and such responses?

As always "more research is needed".

References

1 Fallon KM, Fuller JG, Morely-Forster P. Fat embolization and fatal cardiac arrest during hip arthroplasty with methylmathacrylate. Can J Anesth 2001; 48:626–9.[Abstract/Free Full Text]

2 Byrick RJ. Fat embolism and postoperative coagulopathy. Can J Anesth 2001; 48:618–21.[Free Full Text]

3 Harper CM. An unusual case of the fat embolism syndrome. Intensive Care Med 2000; 26: 819.[Medline]

4 Koessler MJ, Fabiani R, Hamer H, Pitto RP. The clinical relevance of embolic events detected by transesophageal echocardiography during cemented hip arthroplasty: a randomized clinical trial. Anesth Analg 2001; 92: 49–55.[Abstract/Free Full Text]

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