?Fat embolism post-THR

garychleung

PIG Meeting: 1st July 2021

66-year-old lady admitted to ICU with decreased GCS post elective THR

Background

  • CREST syndrome – Raynaud’s and oesophagitis.
  • No DMARD/steroid therapy
  • COPD – mild. Distant ex-smoker

Issues

  • 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.

Discussion

  • 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.