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Background The incidence of cerebral fat embolism (CFE) ranges from 0.9–11%, with a mean mortality rate of around 10%. Although no univocal explanation has been identified for the resulting fat embolism syndrome (FES), two hypotheses are widely thought: the ‘mechanical theory’, and the ‘chemical theory’. The present article provides a systematic review of published case reports of FES following a bone fracture. Methods We searched MEDLINE, Web of Science and Scopus to find any article related to FES. Inclusion criteria were: trauma patients; age ≥ 18 years; and the clinical diagnosis of CFE or FES. Studies were excluded if the bone fracture site was not specified. Results One hundred and seventy studies were included (268 cases). The male gender was most prominent (81.6% vs. 18.4%). The average age was 33 years (±18). The mean age for males (29 ± 14) was significantly lower than for females (51 ± 26) (p < 0.001). The femur was the most common fracture site (71% of cases). PFO was found in 12% of all cases. Univariate and multivariate regression analyses showed the male gender to be a risk factor for FES: RR 1.87 and 1.41, respectively (95%CI 1.27–2.48, p < 0.001; 95%CI 0.48–2.34, p < 0.001). Conclusions FES is most frequent in young men in the third decades of life following multiple leg fractures. FES may be more frequent after a burst fracture. The presence of PFO may be responsible for the acute presentation of cerebral embolisms, whereas FES is mostly delayed by 48–72 h.

Mechanical ventilation during surgery is a highly complex procedure, particularly in cardiothoracic surgery, where patients need to undergo substantial hemodynamic management, involving large fluid exchanges and pharmacological manipulation of vascular resistance, as well as direct manipulation of the lungs themselves. Cardiothoracic surgery is burdened by a high rate of postoperative pulmonary complication (PPC), comorbidity, and mortality. Recent trials have examined various techniques to preserve lung function, although consensus on best practice has yet to be reached. This might be due to the close relationship between the circulatory and pulmonary systems. The use of a technique designed to prevent pulmonary complication might negatively impact the hemodynamics of an already critical patient. Stressinduced lung injury can occur during surgery for various reasons, some of which have yet to be fully investigated. In cardiac surgery, this damage is mainly ascribed to two events: cardiopulmonary bypass (CPB) and sternotomy. In thoracic surgery, on the other hand, overdistention and permissive hyperoxia, both routinely used on one lung to compensate for the collapse of the other, are generally to blame for lung injury. In recent years "protective" ventilation strategies have been proposed to spare lung parenchyma from stressinduced damage. Despite the growing interest in protective ventilation techniques, there are still no clear international guidelines for mechanical ventilation in cardiothoracic surgery. However, some recent progress has been made, with positive clinical outcomes.