Fat embolism and the fat embolism syndrome. A double-blind therapeutic study

Abstract

Fifty-five adults who had sustained a tibial fracture, or a femoral fracture, or both, were subjected to a double-blind randomised study to determine the efficacy of methylprednisolone in treating the fat embolism syndrome. This drug maintained arterial oxygen levels, stabilised or reduced the serum level of free fatty acids, and decreased the risk of the fat embolism syndrome in a statistically significant proportion of patients. Gurd's criteria for the diagnosis of the fat embolism syndrome were found inadequate. Other more sensitive criteria for early diagnosis and effective management were determined. There were no deaths or serious morbidity in our series.

Fat embolism

“…However, gas exchange deteriorates after long bone fractures with or without FE. In 16 of 28 patients with lower limb long bone fractures, the oxygen tension (P a o 2 ) was reported to be less than 7.3 kPa [5] and, similarly, in another study of patients with multiple injuries, the P a o 2 was reported to be less than 9.3 kPa in 90% of patients [8].…”

“…Gurd's criteria have been criticised for being unreliable because fat droplets can frequently be found in the blood of healthy volunteers and trauma patients without any clinical evidence of FES [4]. Lindeque suggested that Gurd's criteria may underdiagnose the syndrome and proposed the following criteria based on respiratory parameters (Table 2) [5]. Any patient with a fractured femur and/or tibia showing one or more of these criteria was judged as having FES.…”

“…The routine use of pulse oximetry may detect early hypoxaemia and allows prompt correction with controlled humidified oxygen therapy [81]. Lindeque found that patients with a P a o 2 , 9.2 kPa on admission were twice as likely to develop hypoxaemia [5]. Whether early administration of oxygen actually prevents the onset of the syndrome by preventing hypoxaemia, further catecholamine response and fat mobilisation remains unclear.…”

“…Possible beneficial effects include stabilisation of the pulmonary capillary membrane, thus reducing the leak that creates interstitial oedema, blunting the inflammatory response, stabilising complement system activation and retarding platelet aggregation [68]. Studies reporting beneficial effects [5,31,82,83] used doses of methyl prednisolone between 9 mg.kg 21 and 90 mg.kg 21 (in divided doses). The results of these trials were impressive, with a 10-fold reduction of FES in one series; however, the only fatality reported in any of these trials was due to overwhelming sepsis in a patient receiving corticosteroids [30].…”

Role of Interleukin-6 as an Early Marker of Fat Embolism Syndrome: A Clinical Study

“…The sample size was small and clinical diagnosis of FES was established using Gurd's criteria [13], which have not been proved as the gold standard clinical diagnostic criteria of FES. Although some researchers believe that Gurd's criteria may underdiagnose FES, there is in fact no gold standard diagnostic criterion to identify this condition and Gurd's criteria are still the most frequently used diagnostic criteria of FES [12,14,15,22]. Some researchers believe that a high index of suspicion and close observation for the subtle signs of FES in vulnerable patients may diagnose the syndrome accurately [12,14,24].…”