Case Report - (2016) Volume 2, Issue 4
Karen J Woittiez* and Jos Le Noble
VieCuri Medical Centre, department of Intensive Care, Netherlands
*Corresponding Author:
Woittiez KJ
VieCuri Medical Centre, department of Intensive Care
Tegelseweg 2105914 BE Venlo, Netherlands
Tel: 31773205317
E-mail: kwoittiez@viecuri.nl
Received date: August 25, 2016; Accepted date: September 20, 2016; Published date: September 27, 2016
Citation: Woittiez KJ, Noble JL. Respiratory Failure after Total Hip Replacement. J Intensive & Crit Care 2016, 2:4.
After a hip replacement a patient developed a severe irreversible obstructive shock due to a fat embolism. A lung biopsy showed fat cells and bone fragments in the pulmonary capillaries.
Keywords
Total hip replacement; Obstructive shock; Fat embolism; Disseminated intravascular coagulation
Introduction
An 82 year old woman fractured her right hip after a fall. A total hip replacement was performed. The operation proceeded uneventfully; however, upon drilling for medullary pin placement, the patient became hemodynamically unstable and was transferred to the intensive care unit postoperatively.
Case Report
The patient was hypotensive, despite treatment with high vasopressor doses. Blood examination showed thrombocytopenia and prolonged clotting time. Subsequently, she became severely hypoxic and developed pulseless electrical activity, but regained cardiac output after cardiopulmonary resuscitation. Transthoracic echocardiography showed a dilated right atrium, increased rightward pressure and diastolic bulging. The patient rapidly developed irreversible obstructive shock. Supportive care was therefore discontinued, after which the patient passed away. During autopsy, extensive intrapulmonary abnormalities were observed: indicating that the capillaries contained fat cells (Figure 1). Our patient died from a fat embolism. We assume that bone marrow was introduced into the venous system due to increased intramedullary pressure during the drilling for femoral intramedullary pin insertion [1], as evidenced by the presence of two bone fragments in the pulmonary capillaries (Figure 2). The fat particles caused lung vessel congestion and secondarily an overstressing of the right heart, which resulted in hypoxemia and acute right-sided heart failure. Furthermore, the bone marrow in the venous vessels caused considerable activation of coagulation with a decrease in thrombocytes and consumptive coagulopathy (disseminated intravascular coagulation).
Figure 1: Lung biopsy. Capillaries filled with holes from fat cells (the fat cells themselves are dissolved during the preparation of the tissue sample), lining up in a row in the center of the image like a string of beads.
Figure 2: Lung biopsy. Pulmonary capillaries filled with fat cells and two bone fragments (pointed out by the arrows), which can be seen as irregular-shaped fragments in the capillaries.
Discussion
Fat embolisms are common in patients with long-bone fractures. Using a transesophageal echocardiography, they can be detected in more than 90% of patients during orthopedic surgery [2,3]. However, it is still unclear why only a small percentage (1-3%) of these patients develops symptomatic fat embolisms [4]. Risk factors for symptomatic fat embolism are patients younger than 35 years, patients suffering from multiple injuries, and patients in whom treatment had been initiated more than 10 h after the trauma [5,6]. Additionally, an elevated intraosseous pressure during orthopedic surgery is a well-known risk factor [7]. Finally, there is increasing evidence that the severity and incidence of symptomatic fat embolisms are decreased when prophylactic corticosteroids are administered to high-risk patients before surgery [8].
