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LETTERS TO EDITOR
Year : 2019  |  Volume : 8  |  Issue : 4  |  Page : 293-295

Immediate postoperative hypoxia–fat embolism syndrome: An unknown sinister


1 Department of Anaesthesia and Critical Care, Command Hospital (Southern Command), Pune, Maharashtra, India
2 Department of Anaesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission15-Mar-2019
Date of Acceptance12-Sep-2019
Date of Web Publication15-Oct-2019

Correspondence Address:
Dr. Saurabh Sud
Department of Anaesthesia and Critical Care, Command Hospital (Southern Command), Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_15_19

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How to cite this article:
Sud S, Dwivedi D, Sawhney S, Singh S. Immediate postoperative hypoxia–fat embolism syndrome: An unknown sinister. Int J Health Allied Sci 2019;8:293-5

How to cite this URL:
Sud S, Dwivedi D, Sawhney S, Singh S. Immediate postoperative hypoxia–fat embolism syndrome: An unknown sinister. Int J Health Allied Sci [serial online] 2019 [cited 2019 Nov 11];8:293-5. Available from: http://www.ijhas.in/text.asp?2019/8/4/293/269243



Sir,

Fat embolism syndrome (FES) with an incidence of 0.5%–29% is commonly caused by traumatic and nontraumatic etiologies.[1] Common traumatic causes include long-bone fractures, pelvic fractures, orthopedic procedures, burns, and liposuction, whereas pancreatitis, diabetes mellitus, and lipid infusion are common nontraumatic causes.[1] The most common risk factors for developing FES are male sex, age between 10 and 40 years, and unstable and multiple fractures.[1]

We present the case of a 52-year-old male weighing 60 kg who developed FES following the application of an external fixator for right tibial fracture under spinal anesthesia (SA). Preoperative investigations were within normal limits. Written informed consent and nil per oral status were confirmed. Standard monitoring ensued. SA block achieved was till T9 level with 3 ml of 0.5% heavy bupivacaine. Intraoperatively, the patient developed hypotension which was managed with aliquots of phenylephrine (total dose 250 μg). Rest of the intraoperative period was uneventful. Twenty minutes later in the postanesthesia care unit, the patient suddenly had difficulty in breathing and became hypoxic, with oxygen saturation decreasing from 98% to 86% on room air. Respiratory rate increased from 10 to 38/min, and heart rate increased from 64 to 120/min. Noninvasive blood pressure (NIBP) rose from 138/78 to 200/120 mmHg. The patient was agitated and had bilateral wheeze with active involvement of accessory muscles of respiration. The patient was reassured and nebulized with 5 mg of salbutamol and 0.5 mg of ipratropium bromide, and infusion of nitroglycerin (NTG) was started at the rate of 5 μg/min to titrate NIBP within 20% of baseline. After stabilization, the patient was shifted to the intensive care unit, and NTG infusion was tapered over 12 h. In view of the high suspicion of FES, enzyme-linked immunosorbent assay D-dimer reflected higher values of 3653 U/ml (normal <500 U/ml). Computed tomography of the lungs and brain could not be done due to resource constraints. On being probed about hypertension, the patient disclosed to be a known hypertensive, on tablet Ramipril 5 mg once a day for the last 2 years, which he did not disclose preoperatively, and had consumed the morning dose on the day of surgery. The patient recovered fully and was discharged after 3 days.

FES commonly develops after 24–72 h of injury and is diagnosed in the presence of petechial rash, neurological manifestations, and respiratory insufficiency. Respiratory symptoms are the earliest to manifest and are seen in 75% of patients, with hypoxia (96%) being the most common.[2] Neurological symptoms (86%) are the most common manifestations, with petechial rash being the least common manifestation.[3] FES during orthopedic intervention generally develops due to increase in the intramedullary pressure, leading to release of bone marrow in blood circulation, which subsequently leads to the activation of clotting system.

Diagnosis of FES is commonly done using the Gurd's and Schonfeld's criteria.[1] Lindeque's criteria with respiratory presentations have been utilized in isolation for diagnosing FES.[1] The Lindeque's criteria include PaO2<60 mmHg, PaCO2>55 mmHg, sustained respiratory rate >35/min and increased work of breathing, use of accessory muscles, dyspnea, tachycardia, and anxiety, which were present in majority in our index case.[1] The Lindeque's criteria and raised d-dimer confirmed the diagnosis of FES in our case. The intraoperative hypotension and postoperative hypertensive emergency could be explained due to the effect of angiotensin-converting enzyme inhibitor with superadded sympthoadrenal activity due to FES. All the other common causes of postoperative hypertension were excluded.[4]

To conclude, anesthesiologists should be wary about the respiratory manifestations of FES which can present in the immediate postoperative period in isolation, thereby raising a high degree of suspicion in such subsets of patients where timely diagnosis and management will limit the morbidity and mortality.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Singh S, Goyal R, Baghel PK, Sharma V. Fat embolism syndrome: A comprehensive review and update. J Orthop Allied Sci 2018;6:56-63.  Back to cited text no. 1
  [Full text]  
2.
Powers KA, Talbot LA. Fat embolism syndrome after femur fracture with intramedullary nailing: Case report Am J Crit Care 2011;20:4-6.  Back to cited text no. 2
    
3.
Shaikh N, Parchani A, Bhat V, Kattren MA. Fat embolism syndrome: Clinical and imaging considerations: Case report and review of literature. Indian J Crit Care Med 2008;12:32-6.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Hazzi R, Mayock R. Perioperative management of hypertension. J Xiangya Med 2018;3:25.  Back to cited text no. 4
    




 

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