PIG Meeting: 1st July 2021
66-year-old lady admitted to ICU with decreased GCS post elective THR
- CREST syndrome – Raynaud’s and oesophagitis.
- No DMARD/steroid therapy
- COPD – mild. Distant ex-smoker
- Revision/re-do THR in Private hospital with standard spinal anaesthetic
- Uneventful intraoperative progress
- Episode of postoperative chest pain. Fentanyl PCA commenced, had 20mcg in total
- 1 hour later, appeared ‘narcotised;’ confusion, pinpoint pupils, and decreased RR
- Fentanyl ceased
- 6 hours post-op, found with GCS 6, no response to naloxone or flumazenil
- BSL, CT brain and CT-Angio normal
- Commenced on Keppra and transferred to JHH ICU
- Intubated on arrival to ICU due to low GCS
- MRI revealed ‘Multiple focal areas of acute infarction and multiple micro-haemorrhages’ involving brainstem and bilateral Thalami.
- Working Diagnosis of fat embolism syndrome
- Troponin rise to 820, no ECG changes. Commenced on aspirin.
- Interesting and very unfortunate case
- Unusual presentation, no hypoxaemia reported but did complain of chest pain
- No PFO on post-op echocardiogram
- Diagnosis of fat embolism is usually based on clinical findings, but biochemical changes may be of value. The major and minor diagnostic criteria by Gurd are outlined below.
- The major criteria are based on the classic triad of respiratory insufficiency, neurological impairment, and a petechial rash.
- For the diagnosis of fat embolism syndrome, at least one major and four minor criteria must be present.