Fat embolism syndrome medical therapy: Difference between revisions
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{{CMG}} {{AE}} {{FT}} | {{CMG}} {{AE}} {{FT}} | ||
==Overview== | ==Overview== | ||
The mainstay of treatment of fat embolism syndrome is supportive care, [[Anticoagulant|anticoagulation]] in some cases and [[corticosteroid]] therapy in severe [[Respiratory system|respiratory]] distress. The main steps followed in conservative management include in ICU supportive care, [[Fluid replacement|fluid resuscitation]], supplemental oxygen, [[Mechanical ventilation|mechanical]] ventilation and intracranial monitoring. | |||
==Medical Therapy== | ==Medical Therapy== | ||
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Following are the main steps followed for the management:<ref name="pmid3818718">{{cite journal| author=Lindeque BG, Schoeman HS, Dommisse GF, Boeyens MC, Vlok AL| title=Fat embolism and the fat embolism syndrome. A double-blind therapeutic study. | journal=J Bone Joint Surg Br | year= 1987 | volume= 69 | issue= 1 | pages= 128-31 | pmid=3818718 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3818718 }} </ref><ref name="pmid15124801">{{cite journal| author=Babalis GA, Yiannakopoulos CK, Karliaftis K, Antonogiannakis E| title=Prevention of posttraumatic hypoxaemia in isolated lower limb long bone fractures with a minimal prophylactic dose of corticosteroids. | journal=Injury | year= 2004 | volume= 35 | issue= 3 | pages= 309-17 | pmid=15124801 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15124801 }} </ref> | Following are the main steps followed for the management:<ref name="pmid3818718">{{cite journal| author=Lindeque BG, Schoeman HS, Dommisse GF, Boeyens MC, Vlok AL| title=Fat embolism and the fat embolism syndrome. A double-blind therapeutic study. | journal=J Bone Joint Surg Br | year= 1987 | volume= 69 | issue= 1 | pages= 128-31 | pmid=3818718 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3818718 }} </ref><ref name="pmid15124801">{{cite journal| author=Babalis GA, Yiannakopoulos CK, Karliaftis K, Antonogiannakis E| title=Prevention of posttraumatic hypoxaemia in isolated lower limb long bone fractures with a minimal prophylactic dose of corticosteroids. | journal=Injury | year= 2004 | volume= 35 | issue= 3 | pages= 309-17 | pmid=15124801 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15124801 }} </ref> | ||
===Conservative management=== | ===Conservative management=== | ||
The following conservative measures are taken to manage fat embolism syndrome:<ref name="pmid2245559">{{cite journal| author=Levy D| title=The fat embolism syndrome. A review. | journal=Clin Orthop Relat Res | year= 1990 | volume= | issue= 261 | pages= 281-6 | pmid=2245559 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2245559 }} </ref><ref name="pmid18278374">{{cite journal| author=Cavallazzi R, Cavallazzi AC| title=[The effect of corticosteroids on the prevention of fat embolism syndrome after long bone fracture of the lower limbs: a systematic review and meta-analysis]. | journal=J Bras Pneumol | year= 2008 | volume= 34 | issue= 1 | pages= 34-41 | pmid=18278374 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18278374 }} </ref> | |||
*In ICU supportive care | *In ICU supportive care | ||
*[[Fluid replacement|Fluid resuscitation]] | *[[Fluid replacement|Fluid resuscitation]] | ||
| Line 16: | Line 17: | ||
*[[Mechanical ventilation]] | *[[Mechanical ventilation]] | ||
*Intracranial monitoring and frequent [[Neurology|neurological]] examination if [[central nervous system]] dysfunction is present. | *Intracranial monitoring and frequent [[Neurology|neurological]] examination if [[central nervous system]] dysfunction is present. | ||
===In ICU supportive care=== | ===In ICU supportive care=== | ||
*Continuous monitoring of vital signs | *Continuous monitoring of vital signs | ||
| Line 26: | Line 28: | ||
===Supplemental oxygen=== | ===Supplemental oxygen=== | ||
* High flow supplemental [[oxygen]] should be insued to maintain [[Artery|arterial]] [[oxygenation]]. | * High flow supplemental [[oxygen]] should be insued to maintain [[Artery|arterial]] [[oxygenation]].<ref name="pmid8196970">{{cite journal| author=Müller C, Rahn BA, Pfister U, Meinig RP| title=The incidence, pathogenesis, diagnosis, and treatment of fat embolism. | journal=Orthop Rev | year= 1994 | volume= 23 | issue= 2 | pages= 107-17 | pmid=8196970 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8196970 }} </ref> | ||
===Anticoagulation=== | ===Anticoagulation=== | ||
| Line 40: | Line 42: | ||
===Corticosteroids=== | ===Corticosteroids=== | ||
The rationale for administering steroids is based on the pro-inflammatory effect of fat [[embolism]]. They are used most commonly in the following patients: | The rationale for administering steroids is based on the pro-inflammatory effect of fat [[embolism]]. They are used most commonly in the following patients:<ref name="pmid16990062">{{cite journal| author=White T, Petrisor BA, Bhandari M| title=Prevention of fat embolism syndrome. | journal=Injury | year= 2006 | volume= 37 Suppl 4 | issue= | pages= S59-67 | pmid=16990062 | doi=10.1016/j.injury.2006.08.041 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16990062 }} </ref> | ||
Those who have life-threatening complications of fat embolism syndrome such as: | Those who have life-threatening complications of fat embolism syndrome such as: | ||
| Line 50: | Line 52: | ||
Preferred regimen (2): Methylprednisone 1-1.5mg/kg/day for 5 days | Preferred regimen (2): Methylprednisone 1-1.5mg/kg/day for 5 days | ||
''' | '''Contraindications:''' | ||
* Increased risk of [[infection]] | * Increased risk of [[infection]] | ||
===Fluid resuscitation=== | ===Fluid resuscitation=== | ||
The aims of fluid resuscitation are as follows: | The aims of fluid resuscitation are as follows:<ref name="pmid19561953">{{cite journal| author=Shaikh N| title=Emergency management of fat embolism syndrome. | journal=J Emerg Trauma Shock | year= 2009 | volume= 2 | issue= 1 | pages= 29-33 | pmid=19561953 | doi=10.4103/0974-2700.44680 | pmc=2700578 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561953 }} </ref><ref name="pmid16990063">{{cite journal| author=Habashi NM, Andrews PL, Scalea TM| title=Therapeutic aspects of fat embolism syndrome. | journal=Injury | year= 2006 | volume= 37 Suppl 4 | issue= | pages= S68-73 | pmid=16990063 | doi=10.1016/j.injury.2006.08.042 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16990063 }} </ref> | ||
* Maintaining intravascular [[volume]] | * Maintaining intravascular [[volume]] | ||
* Binding of fatty acids released into the circulation | * Binding of fatty acids released into the circulation | ||
Latest revision as of 13:15, 5 April 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Feham Tariq, MD [2]
Overview
The mainstay of treatment of fat embolism syndrome is supportive care, anticoagulation in some cases and corticosteroid therapy in severe respiratory distress. The main steps followed in conservative management include in ICU supportive care, fluid resuscitation, supplemental oxygen, mechanical ventilation and intracranial monitoring.
Medical Therapy
The mainstay of treatment of fat embolism syndrome is supportive care, anticoagulation in some cases and corticosteroid therapy in severe respiratory distress. Following are the main steps followed for the management:[1][2]
Conservative management
The following conservative measures are taken to manage fat embolism syndrome:[3][4]
- In ICU supportive care
- Fluid resuscitation
- Supplemental oxygen
- Mechanical ventilation
- Intracranial monitoring and frequent neurological examination if central nervous system dysfunction is present.
In ICU supportive care
- Continuous monitoring of vital signs
- Neurological monitoring
- Daily CBCs
- Chest radiographs
- Echocardiogram
- CT scan
- Serial MRI scans
Supplemental oxygen
- High flow supplemental oxygen should be insued to maintain arterial oxygenation.[5]
Anticoagulation
The goals of anticoagulant therapy are as follows:
- It is administered only if the underlying cause is venous thromboembolism.
- Heparin stimulates the activity of lipase which accelerates the clearance of fat from the circulation.
Complications:
- Increased risk of hemorrhage
- Increased production of free fatty acids from fat break down
Contraindications:
- Pre-existing hematological diseases
- Trauma
Corticosteroids
The rationale for administering steroids is based on the pro-inflammatory effect of fat embolism. They are used most commonly in the following patients:[6]
Those who have life-threatening complications of fat embolism syndrome such as:
Preferred regimen (1): Hydrocortisone 100 mg PO q8h daily for 5 days
Preferred regimen (2): Methylprednisone 1-1.5mg/kg/day for 5 days
Contraindications:
- Increased risk of infection
Fluid resuscitation
The aims of fluid resuscitation are as follows:[7][8]
- Maintaining intravascular volume
- Binding of fatty acids released into the circulation
- Decrease the lung injury
Albumin along with balanced electrolyte solution is recommended.
Mechanical ventilation:
Invasive or non-invasive mechanical ventilation is commonly used.
Mechanical cardiac support devices
- Used in patients with refractory shock
References
- ↑ Lindeque BG, Schoeman HS, Dommisse GF, Boeyens MC, Vlok AL (1987). "Fat embolism and the fat embolism syndrome. A double-blind therapeutic study". J Bone Joint Surg Br. 69 (1): 128–31. PMID 3818718.
- ↑ Babalis GA, Yiannakopoulos CK, Karliaftis K, Antonogiannakis E (2004). "Prevention of posttraumatic hypoxaemia in isolated lower limb long bone fractures with a minimal prophylactic dose of corticosteroids". Injury. 35 (3): 309–17. PMID 15124801.
- ↑ Levy D (1990). "The fat embolism syndrome. A review". Clin Orthop Relat Res (261): 281–6. PMID 2245559.
- ↑ Cavallazzi R, Cavallazzi AC (2008). "[The effect of corticosteroids on the prevention of fat embolism syndrome after long bone fracture of the lower limbs: a systematic review and meta-analysis]". J Bras Pneumol. 34 (1): 34–41. PMID 18278374.
- ↑ Müller C, Rahn BA, Pfister U, Meinig RP (1994). "The incidence, pathogenesis, diagnosis, and treatment of fat embolism". Orthop Rev. 23 (2): 107–17. PMID 8196970.
- ↑ White T, Petrisor BA, Bhandari M (2006). "Prevention of fat embolism syndrome". Injury. 37 Suppl 4: S59–67. doi:10.1016/j.injury.2006.08.041. PMID 16990062.
- ↑ Shaikh N (2009). "Emergency management of fat embolism syndrome". J Emerg Trauma Shock. 2 (1): 29–33. doi:10.4103/0974-2700.44680. PMC 2700578. PMID 19561953.
- ↑ Habashi NM, Andrews PL, Scalea TM (2006). "Therapeutic aspects of fat embolism syndrome". Injury. 37 Suppl 4: S68–73. doi:10.1016/j.injury.2006.08.042. PMID 16990063.