Transoesophageal Echocardiography for the Detection and Prevention of Embolic Episodes during Intramedullary Nailing for Pathological Fractures

Abstract

The introduction of intramedullary nailing in clinical practice became popular at the beginning of the decade of 1980 and gave excellent results. Especially in patients with multiple injuries, their quick mobilisation had as a result the avoidance of complications in the respiratory system [6]. However, there are reports which show that intramedullary nailing can be associated with increased morbidity and mortality due to the appearance of embolic episodes; the most serious of these happen to patients with pathologic fractures [1,12]. Furthermore, in patients with a patent foramen ovale and right to left shunt, emboli can cross from the right to the left ventricle and cause paradoxical embolism with obstruction of the coronary and cerebral vessels [3,8].Transoesophageal echocardiography (TEE) is the most sensitive monitor for the detection of the embolic episodes intraoperatively [5,7,11] and gives an opportunity to research for the decrease of morbidity and mortality. In spite of its continuously increased use intraoperatively, there are rare studies in patients with pathological fractures and these include a small sample of patients. The aim of the present study is to investigate with the help of TEE the frequency and the seriousness of embolic episodes in patients who were submitted for intramedullary nailing for pathological fractures. Material and MethodsThe research started in May 1997 and until now 22 patients with pathological fractures were studied, 10 women and 12 men, with a mean age of 56 years (40 to 72). The patients were submitted for intramedullary nailing of femur, tibia and humerus. 10 pa- AbstractWe performed transoesophageal echocardiography on 22 patients during intramedullary nailing for pathological fractures. Moderate quantities of echogenic signals as a rosary in the screen of TEE (D = 1 mm) were observed in 10 patients during the opening of the bone marrow. Embolic episodes as a snowball (D = 1±5 mm) were observed in all patients during the intramedullary reaming and the introduction of the nail. The haemodynamic changes were related with the duration of the embolism. Two patients developed haemodynamic disorders, treated with 100 % O 2 and vasoconstrictors. Seven patients developed transient but not significant changes of arterial pressure, SaO 2 and P E CO 2. Paradoxical embolisation or fat embolism syndrome were observed in no patients. In one of these patients a flow-patent foramen ovale was detected preoperatively. During the operation and after intravenous fluid loading the right to left shunt flow could not be detected. This may represent a mechanism whereby paradoxical embolisation could be prevented intraoperatively. Transoesophageal echocardiography in intramedullary nailing for pathological fractures may play a useful role in the recording and anaesthesiological treatment of embolic episodes, venous and paradoxical, during these operations.