Can the rate of mortality and neurological recovery be predicted from the time of onset of symptoms and MRI grade in patients with cerebral fat embolism? : a study of 34 patients.

AIMS: The aim of this study was to assess whether it is possible to predict the mortality, and the extent and time of neurological recovery from the time of the onset of symptoms and MRI grade, in patients with the cerebral fat embolism syndrome (CFES). This has not previously been investigated. METHODS: The study included 34 patients who were diagnosed with CFES following trauma between 2012 and 2018. The clinical diagnosis was confirmed and the severity graded by MRI. We investigated the rate of mortality, the time and extent of neurological recovery, the time between the injury and the onset of symptoms, the clinical severity of the condition, and the MRI grade. All patients were male with a mean age of 29.7 years (18 to 70). The mean follow-up was 4.15 years (2 to 8), with neurological recovery being assessed by the Glasgow Outcome Scale and the Mini-Mental State Examination. RESULTS: In all, seven who had early-onset CFES (< 24 hours), and a severe Takahashi grade on MRI, died. There was a significant association between the time of onset of neurological signs and mortality (p = 0.035). Mortality was also significantly associated with a severe Takahashi grade (p < 0.001). Among the 27 surviving patients, 26 (96.3%) recovered completely. One (3.7%) had a cognitive deficit. The mean time to recovery was 4.7 weeks (2 to 13), with late recovery aftereight eight weeks being recorded in three patients. CONCLUSION: There was a significantly increased rate of mortality in patients with CFES who had an early onset of symptoms and a severe grade on MRI. Complete neurological recovery can be expected in most patients with CFES who survive. Cite this article: Bone Joint J 2022;104-B(1):142-149.

Complete neurological recovery from fat embolism syndrome in sickle cell disease after sequential red cell exchange transfusion and therapeutic plasma exchange.

Fat embolism syndrome in sickle cell disease is associated with great mortality, while more than half of survivors suffer severe neurological sequelae. Release of fat droplets leads to obstruction of the microcirculation as well as generation of proinflammatory cytokines that can cause direct tissue injury. Red cell exchange transfusion can be life-saving but the addition of therapeutic plasma exchange may further improve outcomes by removing such inflammatory mediators. Here, we describe the case of a 27-year-old male patient with sickle cell anaemia presenting with typical features of fat embolism syndrome including neurological involvement with greatly reduced level of consciousness. MRI of his brain showed multiple widespread microhemorrhages giving the characteristic "star field" pattern but also a cytotoxic lesion of the corpus callosum, known to be the result of direct neurotoxicity by proinflammatory cytokines. The patient underwent emergency red cell exchange transfusion leading only to modest clinical improvement but fully regained consciousness after three cycles of therapeutic plasma exchange. This case highlights the deleterious effect of the hyperinflammatory state characteristic of many sickle cell complications and supports further exploring the potential benefit from plasma exchange as an adjunct to red cell exchange in order to remove proinflammatory cytokines during acute complications of sickle cell disease.

Autogenous Fat Grafting to the Breast and Gluteal Regions: Safety Profile Including Risks and Complications.

Given the widespread utility and therapeutic potential of autogenous fat grafting, plastic surgeons should be familiar with its safety profile and associated adverse events. This article provides a critical review of the literature and delineates risk factors associated with various complications when grafting to the breast and gluteal regions. The majority of adverse events are related to fat necrosis and require minimal diagnostic or therapeutic intervention. Larger graft volumes, as in cosmetic augmentation, are associated with higher incidences of fatty necrosis. The oncologic safety of fat grafting is supported by multiple clinical studies with thousands of breast cancer patients, albeit predominantly retrospective in nature. Although less frequent, serious complications include fat emboli during gluteal augmentation. Identification of associated risk factors and implementation of proper surgical techniques may minimize the occurrence of life-threatening complications.

Fatal diffuse pulmonary fat microemboli following reperfusion in liver transplantation with the use of marginal steatotic allografts.

Organ shortage is a major cause of delayed liver transplantation and increased waitlist time. The level of donor steatosis is a significant determinant in organ selection. Scarcity of organs has led some programs to expand their acceptable criteria for the percentage of steatosis. We report two cases of liver transplantation of steatotic donor organs that resulted in mortality within hours from transplantation. Postmortem analysis showed evidence of diffuse pulmonary fat microemboli likely originating from the donor organ, with marked preservation reperfusion injury. The mechanism of diffuse fat microemboli in this setting and possible relationship to other perioperative syndromes (transfusion-related lung injury, acute kidney injury, and postreperfusion syndrome) is discussed.

Understanding Fatal Fat Embolism in Gluteal Lipoinjection: A Review of the Medical Records and Autopsy Reports of 16 Patients.

BACKGROUND: Deaths secondary to gluteal lipoinjection are relatively recent events of major importance. However, little is known in relation to their behavior and clinical evolution. Therefore, an analysis was performed of case records from clinical cases that encountered this problem, correlating the results with the findings during autopsies. METHODS: An analysis was performed of records from patients who died secondary to gluteal lipoinjection. Patient-specific data, surgical procedure, clinical picture, evolution, and outcome were analyzed. The findings of the autopsies and the involvement of other organs were also analyzed and correlated. RESULTS: From 2000 to 2009, 16 files were obtained that fulfilled the indicated requirements. There were no statistically significant differences in the general characteristics of the patients, such as age, body mass index, or volume lipoinjected or liposuctioned. The clinical pictures were similar in all cases, and the autopsy findings showed the presence of microembolism in all cases and macroembolism in the most severe cases. CONCLUSIONS: The most significant parameter of severity in patients who undergo gluteal lipoinjection is the presence of fat in macroscopic form in the circulation. The volumes of liposuctioned or lipoinjected fat have little influence. Hypoxemia, hypotension, and bradycardia are the characteristic clinical features. Although there is no specific treatment, immediate aggressive vital support to attempt to stabilize the patient is crucial. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Paroxysmal sympathetic hyperactivity syndrome caused by fat embolism syndrome. / Síndrome de hiperatividade simpática paroxística causada por síndrome da embolia gordurosa.

Paroxysmal sympathetic hyperactivity represents an uncommon and potentially life-threatening complication of severe brain injuries, which are most commonly traumatic. This syndrome is a clinical diagnosis based on the recurrent occurrence of tachycardia, hypertension, diaphoresis, tachypnea, and occasionally high fever and dystonic postures. The episodes may be induced by stimulation or may occur spontaneously. Underdiagnosis is common, and delayed recognition may increase morbidity and long-term disability. Trigger avoidance and pharmacological therapy can be very successful in controlling this complication. Fat embolism syndrome is a rare but serious complication of long bone fractures. Neurologic signs, petechial hemorrhages and acute respiratory failure constitute the characteristic presenting triad. The term cerebral fat embolism is used when the neurological involvement predominates. The diagnosis is clinical, but specific neuroimaging findings can be supportive. The neurologic manifestations include different degrees of alteration of consciousness, focal deficits or seizures. Management is supportive, but good outcomes are possible even in cases with very severe presentation. We report two cases of paroxysmal sympathetic hyperactivity after cerebral fat embolism, which is a very uncommon association.

A hiperatividade simpática paroxística representa uma complicação incomum, com potencial risco à vida, de lesões cerebrais graves, mais comumente de origem traumática. Seu diagnóstico clínico se baseia na manifestação recorrente de taquicardia, hipertensão, diaforese, taquipneia e, às vezes, febre, além de posturas distônicas. Os episódios podem ser induzidos por estímulos ou ocorrer de forma espontânea. É comum que ocorra subdiagnóstico desta síndrome, e o retardamento de seu reconhecimento pode aumentar a morbidade e a incapacidade em longo prazo. Evitar os desencadeantes e a farmacoterapia podem ter muito sucesso no controle desta complicação. A síndrome da embolia gordurosa é uma complicação rara, mas grave, das fraturas de ossos longos. Sinais neurológicos, petéquias hemorrágicas e insuficiência respiratória aguda são as características que constituem seu quadro clínico. O termo "embolia gordurosa cerebral" é estabelecido quando predomina o envolvimento neurológico. O diagnóstico é clínico, porém achados específicos de neuroimagem podem confirmá-lo. As manifestações neurológicas incluem diferentes graus de alteração da consciência, défices focais ou convulsões. Seu tratamento é de suporte, porém são possíveis desfechos favoráveis, mesmo nos casos com apresentação grave. Relatamos dois casos de hiperatividade simpática paroxística após embolia gordurosa cerebral, uma associação muito incomum.

Síndrome de hiperatividade simpática paroxística causada por síndrome da embolia gordurosa / Paroxysmal sympathetic hyperactivity syndrome caused by fat embolism syndrome

RESUMO A hiperatividade simpática paroxística representa uma complicação incomum, com potencial risco à vida, de lesões cerebrais graves, mais comumente de origem traumática. Seu diagnóstico clínico se baseia na manifestação recorrente de taquicardia, hipertensão, diaforese, taquipneia e, às vezes, febre, além de posturas distônicas. Os episódios podem ser induzidos por estímulos ou ocorrer de forma espontânea. É comum que ocorra subdiagnóstico desta síndrome, e o retardamento de seu reconhecimento pode aumentar a morbidade e a incapacidade em longo prazo. Evitar os desencadeantes e a farmacoterapia podem ter muito sucesso no controle desta complicação. A síndrome da embolia gordurosa é uma complicação rara, mas grave, das fraturas de ossos longos. Sinais neurológicos, petéquias hemorrágicas e insuficiência respiratória aguda são as características que constituem seu quadro clínico. O termo "embolia gordurosa cerebral" é estabelecido quando predomina o envolvimento neurológico. O diagnóstico é clínico, porém achados específicos de neuroimagem podem confirmá-lo. As manifestações neurológicas incluem diferentes graus de alteração da consciência, défices focais ou convulsões. Seu tratamento é de suporte, porém são possíveis desfechos favoráveis, mesmo nos casos com apresentação grave. Relatamos dois casos de hiperatividade simpática paroxística após embolia gordurosa cerebral, uma associação muito incomum.

ABSTRACT Paroxysmal sympathetic hyperactivity represents an uncommon and potentially life-threatening complication of severe brain injuries, which are most commonly traumatic. This syndrome is a clinical diagnosis based on the recurrent occurrence of tachycardia, hypertension, diaphoresis, tachypnea, and occasionally high fever and dystonic postures. The episodes may be induced by stimulation or may occur spontaneously. Underdiagnosis is common, and delayed recognition may increase morbidity and long-term disability. Trigger avoidance and pharmacological therapy can be very successful in controlling this complication. Fat embolism syndrome is a rare but serious complication of long bone fractures. Neurologic signs, petechial hemorrhages and acute respiratory failure constitute the characteristic presenting triad. The term cerebral fat embolism is used when the neurological involvement predominates. The diagnosis is clinical, but specific neuroimaging findings can be supportive. The neurologic manifestations include different degrees of alteration of consciousness, focal deficits or seizures. Management is supportive, but good outcomes are possible even in cases with very severe presentation. We report two cases of paroxysmal sympathetic hyperactivity after cerebral fat embolism, which is a very uncommon association.

Fatal Complications of Aesthetic Techniques: The Gluteal Region.

Cosmetic procedures are common and utilize many techniques to obtain aesthetically good outcomes for patient satisfaction with acceptable safety standards. Cosmetic procedures that involve the gluteal region are becoming increasingly popular as various procedures can target the gluteal region such as liposuction, tumescent liposuction, cosmetic filler injections, autologous fat transfer, depot drug delivery, and implants. Complications of cosmetic gluteal procedures can be localized or systemic with systemic complications being responsible for most deaths. These reported systemic complications include sepsis, thromboembolism, fat embolism with or without fat embolism syndrome, macroscopic fat embolism, anesthesia-related and blood volume abnormalities. We herein report 10 deaths due to elective gluteal cosmetic procedures. Autologous fat transfer (fat grafting, lipoinjection) following liposuction resulted in 8 of 10 fatal outcomes of the gluteal aesthetic procedures. A comprehensive discussion of gluteal anatomy, gluteal contouring procedures, and the approach to such cases is presented along with the autopsy findings of the reported cases.

Report on Mortality from Gluteal Fat Grafting: Recommendations from the ASERF Task Force.

Background: Gluteal fat grafting is among the fastest growing aesthetic procedures in the United States and around the world. Given numerous anecdotal and published reports of fatal and nonfatal pulmonary fat embolism resulting from this procedure, the Aesthetic Surgery Education and Research Foundation (ASERF) formed a Task Force to study this complication. Objectives: To determine the incidence of fatal and nonfatal pulmonary fat embolism associated with gluteal fat grafting and provide recommendations to decrease the risks of the procedure. Methods: An anonymous web-based survey was sent to 4843 plastic surgeons worldwide. Additional data on morbidity and mortality was collected through confidential interviews with plastic surgeons and medical examiners, public records requests for autopsy reports in the United States, and through the American Association for the Accreditation of Ambulatory Surgical Facilities (AAAASF). Results: Six hundred and ninety-two (692) surgeons responding to the survey reported 198,857 cases of gluteal fat grafting. Over their careers, surgeons reported 32 fatalities from pulmonary fat emboli as well as 103 nonfatal pulmonary fat emboli. Three percent (3%) of respondents experienced a patient fatality and 7% of respondents reported at least one pulmonary fat embolism in a patient over their careers. Surgeons reporting the practice of injecting into the deep muscle experienced a significantly increased incidence rate of fatal and nonfatal pulmonary fat emboli. Twenty-five fatalities were confirmed in the United States over the last 5 years through of autopsy reports and interviews with surgeons and medical examiners. Four deaths were reported from 2014 to 2015 from pulmonary fat emboli in AAAASF facilities. Conclusions: Despite the growing popularity of gluteal fat grafting, significantly higher mortality rates appear to be associated with gluteal fat grafting than with any other aesthetic surgical procedure. Based on this survey, fat injections into the deep muscle, using cannulae smaller than 4 mm, and pointing the injection cannula downwards should be avoided. More research is necessary to increase the safety of this procedure.

Profilaxia da síndrome de embolia gordurosa: uma análise atual / Prophylaxis of fat embolism syndrome: a current analysis

INTRODUÇÃO: Analisar dados da internet relacionados a mortes por embolia gordurosa, inicio da doença, e outras informações podem determinar a realidade atual no Brasil relacionada à incidência da síndrome de embolia gordurosa e qualquer repercussão na mídia, e também revisar as metodologias de prevenção e quais são os melhores métodos disponíveis para tratar a doença. MÉTODOS: Uma pesquisa no google foi conduzida de Janeiro de 2000 a Janeiro de 2014 utilizando os descritores "cirurgia plástica" e "morte". Foram incluídos e revisados artigos contendo as palavras "embolia", "embolia gordurosa" e "complicações em (ou de) cirurgia plástica". RESULTADOS: Incluiu-se 235 matérias novas relevantes ao longo dos 14 anos. Houve 45 casos de óbito relacionados com cirurgia plástica que ofereceu poucos dados para individualização. Desses pacientes, 44 eram mulheres. As causas possíveis mencionadas foram embolia pulmonar (cinco casos), perfuração das vísceras (cinco casos), hipertermia maligna (três casos), anestesia (dois casos), choque anafilático (dois casos), embolia gordurosa (um caso confirmado), e "outros" (cinco casos). CONCLUSÃO: Diretrizes de prevenção para embolia gordurosa em cirurgia plástica são requeridas, porém, há também necessidade de mais estudos baseados em evidência para entender mais claramente quais são os melhores métodos.

INTRODUCTION: To analyze data from the internet on deaths from fat embolism, time of onset, and other information that could determine current reality in Brazil regarding fat embolism syndrome incidence and any ,media repercussions, and also to review methods of prevention and what are the best methods available to treat this disease. METHODS: A Google search was conducted from January 2000 to January 2014 using the keywords "plastic surgery" and "death." We included and reviewed articles containing the words "embolism", "fat embolism" and "complications in (or of) plastic surgery". RESULTS: We included 235 relevant news stories over the 14 included years. There were 45 cases of death related with plastic surgery that offered few data for individualization. Of these patients, 44 were women. Possible causes mentioned were pulmonary embolism (five cases), perforation of viscera (four cases), malignant hyperthermia (three cases), anesthesia (two cases), anaphylactic shock (two cases), fat embolism (one confirmed case), and "other" (five cases). CONCLUSION: Guidelines to prevent fat embolism in plastic surgery are needed, however, there is also the need of more evidence based studies to understand more clearly what methods are best.

Deaths Caused by Gluteal Lipoinjection: What Are We Doing Wrong?

BACKGROUND: Intramuscular gluteal lipoinjection has become one of the most commonly used surgical procedures for achieving improvement in the gluteal contour; however, there are few studies that report and analyze the causes of secondary death from this surgical procedure. METHODS: An analysis of secondary deaths from gluteal lipoinjection procedures was performed in Mexico and Colombia over periods of 10 and 15 years, respectively. In Mexico, the study was performed through a survey of all members of the Mexican Association of Reconstructive, Plastic and Aesthetic Surgery. In Colombia, the study was performed through an analysis of deaths and autopsies documented by the National Institute of Legal Medicine and Forensic Sciences Regional Bogotá. RESULTS: A total of 413 Mexican plastic surgeons reported 64 deaths related to liposuction, with 13 deaths caused by gluteal lipoinjection. In Colombia, nine deaths were documented. Of the 13 deaths in Mexico, eight (61.6 percent) occurred during lipoinjection, whereas the remaining five (38.4 percent) occurred within the first 24 hours. In Colombia, six deaths (77.7 percent) occurred during surgery and three occurred (22.2 percent) immediately after surgery. In the Colombian autopsy results, seven cases of macroscopic fat embolism and two cases with a microscopic embolism were reported, with abundant fatty tissue in the infiltrated gluteal muscles. CONCLUSIONS: In this study, the authors found that intramuscular gluteal lipoinjection is associated with mortality caused by gluteal blood vessel damage allowing macroscopic and microscopic fat embolism; therefore, buttocks lipoinjection should be performed very carefully, avoiding injections into deep muscle planes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Lipoaspiração e embolia gordurosa: revisão de literatura / Liposuction and fat embolism: a literature review

A cirurgia de lipoaspiração é com alguma frequência relacionada a consequências dramáticas ou fatais, causando grande repercussão no meio médico e principalmente na mídia leiga. Esse fato não deve fazer com que o cirurgião plástico evite essa cirurgia, mas sim estimulá-lo a conhecer profundamente a fisiopatologia inerente ao procedimento, buscando meios embasados de realizá-lo da forma mais segura possível, reduzindo ao máximo os riscos de complicações, principalmente as mais graves. Esse artigo teve o objetivo de realizar uma revisão bibliográfica a respeito especificamente da embolia gordurosa causada pela lipoaspiração, relacionada inúmeras vezes a pós-operatórios dramáticos e fatais. Além disso, ressalta alguns cuidados preventivos para uma maior segurança com esse procedimento.

Liposuction surgery is often associated with severe or fatal consequences, causing great repercussions in the medical field, and especially in the lay media . This should not cause the plastic surgeon to avoid the procedure, but rather should promote deeper knowledge of the basic pathophysiology. All means to accomplish the surgery in the safest possible way should be utilized, to minimize the risk of complications, especially the most severe risks. This article reviews the literature on liposuction-induced fat embolism, which is often associated with severe complications in the postoperative period, and even fatal outcomes. In addition, this study highlights several preventive measures that can be adopted to ensure greater safety of this procedure.

Bone marrow necrosis and fat embolism syndrome in sickle cell disease: increased susceptibility of patients with non-SS genotypes and a possible association with human parvovirus B19 infection.

Fat embolism syndrome (FES) due to extensive bone marrow necrosis (BMN) in sickle cell disease (SCD) is a potentially under-diagnosed complication associated with severe morbidity and mortality. We identified 58 cases reported in the world literature to date. Typically, patients presented with a seemingly uncomplicated vaso-occlusive crisis (VOC) and subsequently deteriorated rapidly with a drop in their haemoglobin and platelets, development of respiratory failure, encephalopathy and varying degrees of involvement of other systems. Overall mortality in the reported cases was 64% but differed according to the use of transfusion and was 29%, 61% and 91% for patients receiving exchange, top-up or no transfusion respectively. Patients most at risk appear to be those with a "milder" form of SCD as 81% of patients had a genotype other than HbSS and the majority had no history of significant sickle-related complications. Human parvovirus B19 (HPV B19) infection was documented in 24% of cases.

[Fat embolism syndrome in skeletal trauma: particularities of the diagnosis, economic aspects and the role of non-invasive ventilation in intensive care].

The article deals with a multicenter study that demonstrates the possibility and feasibility of noninvasive ventilation in patients with skeletal trauma complicated wiith fat embolism syndrome. The authors found additional criteria for the severity of the condition of patients with trauma. Important criteria for the choose a type of ventilation (non-invasive and invasive) is the lack of consciousness, desynchronization of a patient with ventilator and the need for a specialized regimes or miorelaxation to synchronize with the respirator.

[Forensic analysis of death caused by fat embolism: A study of 20 autopsy cases].

OBJECTIVE: To analyze the general and forensic pathological characteristics of death due to fat embolism syndrome (FES) and to provide reference data for forensic identification. METHODS: Twenty autopsy cases due to FES were selected from the forensic center of a medical college from 1999 to 2012. The general and forensic pathological characteristics such as the ways and types of injuries, clinical manifestation and the pathological changes were summarized. RESULTS: Fat embolism mainly occurred after long bone fracture or a large area of soft tissue injury with the majority of cases being fat embolism of lung and occasional cases being combined embolisms of lung and brain as well. The onset of symptoms appeared shortly after the injury or surgery. Lipid droplets could be observed within small pulmonary vessels and verified by special staining. CONCLUSION: There are particular characteristics in death due to FES in concern with types of injuries, onset of symptoms and pathological findings. In order to find out the direct evidence of FES, special staining (oil red O staining) can be used in the forensic identification.