Rare, fatal pulmonary fat embolism after acupuncture therapy: A case report and literature review.

BACKGROUND: Death from nontraumatic pulmonary fat embolism associated with minor soft tissue contusion, surgery, cancer chemotherapy, hematologic disorders and so on has been reported. Patients often present with atypical manifestations and rapid deterioration, making diagnosis and treatment difficult. However, there are no reported cases of death from pulmonary fat embolism after acupuncture therapy. This case emphasizes that the stress induced by acupuncture therapy, a mild soft tissue injury, plays an important role in pulmonary fat embolism. In addition, it suggests that in such cases, pulmonary fat embolism as a complication of acupuncture therapy needs to be taken seriously, and autopsy should be used to identify the source of fat emboli. CASE PRESENTATION: The patient was 72 years old female and experienced dizziness and fatigue after silver-needle acupuncture therapy. She experienced a significant drop in blood pressure and died 2 h later despite treatment and resuscitation. A systemic autopsy and histopathology examination (H&E and Sudan Ⅲ staining) were performed. More than 30 pinholes were observed in the lower back skin. Focal hemorrhages were seen surrounding the pinholes in the subcutaneous fatty tissue. Microscopically, numerous fat emboli were observed in the interstitial pulmonary arteries and alveolar wall capillaries, in addition to the vessels of the heart, liver, spleen and thyroid gland. The lungs showed congestion and edema. The cause of death was identified as pulmonary fat embolism. CONCLUSION: This article suggests that high vigilance for risk factors and the complication of pulmonary fat embolism following silver-needle acupuncture therapy should be exercised. In postmortem examinations, it should be pay attention that the peripheral arterial system and the venous system draining from non-injured sites should be examined for the formation of fat emboli, which can help distinguish posttraumatic and nontraumatic pulmonary fat embolism.

High-dose rosuvastatin treatment for multifocal stroke in trauma-induced cerebral fat embolism syndrome: a case report.

BACKGROUND: Fat embolism syndrome is a life-threatening condition with treatment centering on the provision of excellent supportive care and early fracture fixation. No pharmacologic intervention has yet shown any clear benefit. We used high-dose rosuvastatin specifically for its anti-inflammatory effects to treat a patient with severe fat embolism syndrome. We also suggest that magnetic resonance imaging and transcranial Doppler studies are helpful in establishing the diagnosis and for monitoring the patient's course. PATIENT: A 17-year-old boy developed severe cerebral fat embolism syndrome with multifocal strokes after sustaining bilateral femur fractures. RESULTS: In spite of profound and prolonged neurological impairment, our patient experienced dramatic recovery by the time he was discharged from inpatient rehabilitation several weeks after his initial injury. Magnetic resonance imaging revealed the classic "starfield" pattern of infarcts on diffusion-weighted sequences early in the illness. Additionally, serial transcranial Doppler studies demonstrated dramatically elevated microembolic events that resolved completely during the course of treatment. CONCLUSION: We feel that the acute administration of high-dose rosuvastatin early in the development of our patient's illness may have contributed to his ultimate recovery. Therapeutic guidelines cannot be extrapolated from a single patient, but our experience suggests that statin therapy could be potentially beneficial for individuals with severe fat embolism syndrome, and this approach deserves further clinical evaluation. Additionally, the diagnosis and monitoring of cerebral involvement in fat embolism syndrome is facilitated by both magnetic resonance imaging and transcranial Doppler studies.

Symptomatic pulmonary lipiodol embolism after transarterial chemoembolization for hepatic malignant tumor: clinical presentation and chest imaging findings.

BACKGROUND: Pulmonary lipiodol embolism after transarterial chemoembolization (TACE) was rare and life-threatening, occasionally reported in previous literatures. We aimed to review the records of 11 patients with pulmonary oily embolism and analyze their characteristics of radiographic findings and risk factors. METHODS: Records of 478 consecutive patients who underwent 1 026 percutaneous TACE procedures were retrospectively analyzed. Eleven cases with respiratory symptoms were identified as having symptomatic pulmonary lipiodol embolism after TACE. Data of these patients, including clinical presentation, techniques of TACE, imaging features of tumor and chest imaging findings, were assessed. RESULTS: Eleven (2.3%) of 478 consecutive patients who underwent percutaneous TACE procedures had a pulmonary oily embolism after procedures. The mean size of target tumors embolized was (13.6 ± 2.0) cm. All were hyper-vascular. The mean volume of lipiodol was (21.8 ± 8.2) ml. Pulmonary oily embolisms were revealed within 12-48 hours after TACE. The most severe respiratory symptoms and imaging abnormalities of the eight patients who survived presented between 2 and 5 days after TACE, becoming normal between 12 and 35 days after TACE. Three patients died. Chest CT revealed retention of radiopaque lipiodol in lungs. CONCLUSIONS: Pulmonary lipiodol embolism occurs easily in patients who have large hyper-vascular hepatic malignant tumor. The high-density lipiodol deposition in the lung field can be used as diagnostic feature.

Molecular-biological analysis of acute lung injury (ALI) induced by heat exposure and/or intravenous administration of oleic acid.

The aim of this study was to molecular-biologically investigate the interaction between heat exposure and pulmonary fat embolization in regards to the development of acute lung injury (ALI). Ten-week-old Wistar male rats were divided into four groups: (1) oleic acid injected into caudal vein after heat exposure, (2) oleic acid injected without heat exposure, (3) soybean oil injected after heat exposure, and (4) soybean oil injected without heat exposure, and then mRNA expression of eight inflammatory mediators related to ALI/acute respiratory distress syndrome (ARDS) and heat shock protein 70 (Hsp70) in lung was determined 1h after the injection. mRNA expression of interleukin 1 beta (Il1b), tumor necrosis factor alpha (Tnfa), vascular endothelial growth factor A (Vegfa), transforming growth factor beta 1 (Tgfb1) and Hsp70 was significantly increased by heat exposure, while that of Il1b, interleukin 6 (Il6), Tnfa, macrophage inflammatory protein 2 (Mip2) and granulocyte macrophage-colony stimulating factor (Gm-csf) was significantly elevated by the injection of oleic acid. Moreover, the expressions of inflammatory cytokines and chemokines in lung almost paralleled their mRNA expressions. In particular, IL-1ß expression was synergistically elevated by heat exposure followed by injection of oleic acid. Additionally, IL-6 expression tended to increase under the same conditions as well. It is likely that heat exposure itself injures lung tissue within a short time, and that more than two conditions which induce ALI/ARDS interact with each other synergistically, exacerbating the development of ALI/ARDS.

Efficacy of a new oxygenator-integrated fat and leukocyte removal device.

We evaluated the effectiveness of a new oxygenator-integrated device for removing lipid particles and leukocytes from shed mediastinal blood in 20 patients undergoing elective cardiac surgery under cardiopulmonary bypass. Another 20 patients undergoing cardiac surgery without the device served as controls. After filtration with the RemoveLL device, lipid particles, leukocytes, and fats were significantly reduced compared to preoperative levels. In the control group, blood fats and lipid particles at the end of cardiopulmonary bypass were significantly increased compared to preoperative levels. Leukocyte counts at the end of bypass were significantly lower in patients who had the filtration device compared to the control group. Platelets counts and hematocrit changes were not significantly different between the 2 groups.

Subcutaneous corn oil injections, fat embolization syndrome, and death.

An unlicensed practitioner performing subcutaneous injections of large volumes of corn oil caused the death of one of her clients and life-threatening neurologic complications of a second client from systemic fat embolism. Several additional clients also came forward to report other serious complications they had suffered from similar procedures. The clinicopathologic and investigative findings from these cases are described. In both instances of fat embolization, the diagnosis was overlooked by hospital staff because of insufficient or misleading clinical history. The local and systemic pathologic manifestations of corn oil injections in 1 victim who died several days later from multiple organ failure are described. The clinical history and course of another who survived after 8 days of hospitalization are also presented. Similarities with complications from other forms of cosmetic oil injections are discussed. Laboratory analyses applied to confirm the nature of the injected oil and the course of criminal prosecution are also described.

Cardiorespiratory effects of venous lipid micro embolization in an experimental model of mediastinal shed blood reinfusion.

BACKGROUND: Retransfusion of the patient's own blood during surgery is used to reduce the need for allogenic blood transfusion. It has however been found that this blood contains lipid particles, which form emboli in different organs if the blood is retransfused on the arterial side. In this study, we tested whether retransfusion of blood containing lipid micro-particles on the venous side in a porcine model will give hemodynamic effects. METHODS: Seven adult pigs were used. A shed blood surrogate containing 400 ml diluted blood and 5 ml radioactive triolein was produced to generate a lipid embolic load. The shed blood surrogate was rapidly (<2 minutes) retransfused from a transfusion bag to the right atrium under general anesthesia. The animals' arterial, pulmonary, right and left atrial pressure were monitored, together with cardiac output and deadspace. At the end of the experiment, an increase in cardiac output and pulmonary pressure was pharmacologically induced to try to flush out lipid particles from the lungs. RESULTS: A more than 30-fold increase in pulmonary vascular resistance was observed, with subsequent increase in pulmonary artery pressure, and decrease in cardiac output and arterial pressure. This response was transient, but was followed by a smaller, persistent increase in pulmonary vascular resistance. Only a small portion of the infused triolein passed the lungs, and only a small fraction could be recirculated by increasing cardiac output and pulmonary pressure. CONCLUSION: Infusion of blood containing lipid micro-emboli on the venous side leads to acute, severe hemodynamic responses that can be life threatening. Lipid particles will be trapped in the lungs, leading to persistent effects on the pulmonary vascular resistance.

Circulating particles during cardiac surgery.

Shed blood is known to be a source of lipid micro-emboli in cardiac surgery. The aim of this study was to characterize the occurrence of these particles at different stages of the operation, and to study their occurrence in the circulation at multiple time-points after the retransfusion of shed blood. Forty-four patients undergoing routine surgery with cardiopulmonary bypass were included. Blood was sampled from the surgical field at different sampling locations during the operation. Shed blood was collected in a transfusion bag and retransfused. After which, blood was sampled from the arterial line of the heart-lung machine. A Coulter counter was used for particle determinion. The mean volume of shed blood collected was 340+/-215 ml. Particles in the size range 10-60 microm were found at varying concentrations, with the highest concentrations being found in blood collected after cannulation and from the pleura. After retransfusion of this blood, a biphasic response was seen in the blood drawn from the efferent line of the heart-lung machine. Particles are found in shed blood at all times during cardiac surgery, and when this blood was retransfused an increase was seen in particle concentration in the heart-lung machine.

Relationship between pulmonary fat embolism and core body temperature in rats with a severe fatty liver.

We previously demonstrated that pulmonary fat embolism was induced by elevation of the core body temperature, in rats with a fatty liver. The aim of the present examination was to investigate the core body temperature at which pulmonary fat embolism developed capillaries through exposure to a high temperature, in rats with a fatty liver. Following heat stress, pulmonary fat embolism was observed to a slight degree at a core body temperature of 41 and 42 degrees C, whereas the severity of pulmonary fat embolism was greatly increased and was classified as severe at a core body temperature of 43 degrees C. Moreover, the concentrations of aspartate aminotransferase and alanine aminotransferase within plasma were significantly increased at a core body temperature of 43 degrees C. These results clearly indicate that the development of pulmonary fat embolism could be related to hyperthermia at above 42 degrees C following heat stress, and that fat emboli may be derived from the fatty liver itself. It is thus likely that pulmonary fat embolism can be considered as one form of evidence of hyperthermia in an individual with a fatty liver.

Noncardiac surgery brain injury: etiologic factors and prevention.

EXCERPT: During total joint arthroplasty, showers of bony spicules, marrow fat, and clot are carried by venous blood to the lungs, creating conditions not unlike those present in patients who have suffered traumatic long bone fractures. There is recent evidence that, like the fat embolism syndrome (FES), which often has a component of neurologic dysfunction, total joint arthroplasty and femoral nailing are associated with intraoperative brain embolization as determined by transcranial Doppler ultrasonography, and magnetic resonance brain imaging. Although there are good data demonstrating that intraoperative brain embolization occurs during total joint arthroplasties, the makeup and, even more importantly, the clinical significance of these emboli remain speculative. Brain microemboli resulting from cardiac surgery occur by the millions and may cause focal ischemia resulting in significant neurologic dysfunction. Our studies suggest that the major source of these microemboli is lipid droplets of the patient's fat that drip into the blood in the surgical field. This lipid-laden blood is aspirated and then returned to the patient via the cardiopulmonary bypass (CPB) apparatus. Our investigations have focused on the causes (microemboli), consequences (brain damage), and strategies for elimination of brain lipid microemboli resulting from salvaged blood collected during surgery.

[Fat embolism after intrapenile injection of sweet almond oil]. / Embolie graisseuse après injection intrapénienne d'huile d'amande douce.

We report a case of fat embolism following self injection of vegetable oil in the penis, to treat an impotence. The patient developed respiratory failure and neurological disorders as confusion. A chest roentgenogram revealed diffuse alveolar infiltrate. Initially, he presented an hemoconcentration, and fat globules in his urine. The outcome was favourable in 72 hours, with oxygen and hydration. The diagnosis of fat embolism was made after neurological improvement: the patient admitted to injection his penis with vegetable oil, in his corpus cavernosum.

The pathogenesis of fat embolism.

Fat embolism is a common autopsy finding in patients with or without a history of trauma. There are two basic mechanisms causing fat to embolize. Depot-derived fat embolism arises by disruption of depot fat, usually as a result of trauma, allowing direct entry into the bloodstream. Plasma-derived fat embolism is caused by agglutination of endogenous or infused exogenous fat such as Intralipid, with consequent embolism. Chylomicrons and Intralipid liposomes are known to undergo calcium-dependent agglutination by C-reactive protein (CRP), and this may play a role in vivo in this type of fat embolism.

Fat embolism syndrome caused by vegetable oil injection.

We present a case of fat embolism syndrome following vegetable oil injection for augmentation mammaplasty. Although vegetable oil is a stable neutral fat under usual storage conditions, it caused fat embolism and pulmonary injury in this patient. We investigated this mechanism by compound analysis of the injected oil, transbronchial lung biopsy and special staining of alveolar macrophages. This is the first description of the human response to vegetable oil injection. These data should aid in the investigation of the side effects of many types of lipids which may be applied to humans for various purposes in the future.

[The origin of non-emulsified fat during autotransfusions in elective hip surgery]. / Untersuchung zur Herkunft von entemulgiertem Fett bei Autotransfusionen in der elektiven Hüftchirurgie.

In addition to hemodilution and preoperative blood donations, mechanical intraoperative autotransfusion (MAT) is an important method of preventing or minimizing the transfusion of homologous blood in operations with major blood loss. Using cell separators allows most of the problems of MAT to be solved, but the processed red cell concentrates of patients having hip joint replacement contain fat. Due to the high risk of fat embolism during bone surgery, as well as other circulatory problems, it is of interest whether the infusion of up to 15 ml of fat does not expose patients to an even higher risk. This study aimed to research the pathogenesis of fat embolism and possibly support one of the existing theories. METHODS. Semiquantitative oil measurement: in 45 cases with first insertion of hip joint prosthesis and 16 cases with change of prosthesis MAT was used intra- and postoperatively. For comparison, 10 patients with aortic aneurysm repair were checked for fat as well. In these cases MAT was only used intraoperatively. After the red cell concentrate was processed there was a time lag of 10 min to allow better sedimentation of fat. At the end of retransfusion 50 ml of blood were saved. They were then separated into 10-ml plastic tubes, centrifuged, and fat content was measured using a mm-scale. The results were transformed to ml by means of a previously determined calibration. Analogous to hematocrit values, it was thus possible to establish a lipocrit for these patients. In another 16 cases of hip surgery we carried out cholesterol/triglyceride investigations in red cell concentrates, and in 5 cases analysis of the fatty acids by gas chromatography was performed. RESULTS. The lack of an emulsifier causes biochemical analysis of cholesterol-triglyceride levels to be impossible. Therefore, triglycerides and cholesterol in MAT blood were below normal levels although a high quantity of fat could be seen in the blood. No oil was found in any of the patients in the vascular surgical group. There were 61 patients in the orthopedic group; no oil was found in 34.4%, we found 1-2 ml in 16.4%, and in 49.2% there was more than 2 ml of oil. With regard to age, sex, weight, height, and deviation from Broca index no significant difference in lipocrit could be seen. Differences in lipocrit were observed depending on the type of operation (i.e. new insertion/change of hip prosthesis), these were not significant possibly due to the small number of patients undergoing a change of prosthesis. The more MAT blood was transfused, the more significant were the rises in lipocrit level. The rinsing solution itself (1000 ml NaCl 0.9% with heparin 30,000 IU) does not influence the oil concentrations. Gas chromatography revealed that there was more than 40% oleic acid and 20% palmitic acid. Combined with linoleic acid, this comprised 4/5 of the total amount of oil (Table 3)...

Mineral oil embolization and lipid pneumonia in an infant treated for Hirschsprung's disease.

A 5-month-old infant girl with Hirschsprung's disease died 1 month after colostomy as a result of mineral oil embolism and lipid pneumonia. She had received multiple mineral oil enemas and irrigations as treatment for impacted stools. Mineral oil peritonitis was present on the surface of the bowel adjacent to the stoma and covered large portions of the surface of the liver and spleen. There was 600 cc of slightly cloudy and bloody peritoneal fluid. The peritoneal exudate contained bacteria that were associated with only a minimal inflammatory reaction. This case calls attention to a previously unreported complication of the use of mineral oil.