PULMONARY EMBOLISM - BLOOD VS OTHER?

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Fat embolism syndrome (FES) is a rare etiology with poor prognosis and high mortality rate. The more common causes include orthopedic surgery. Here we present an extremely rare case of FES due to an outpatient elective surgery of fat grafting. Currently there is no other treatment for FES other than supportive care. CASE PRESENTATION: Patient is a 43 year old female with a past medical history for obesity with a strong family history of breast cancer and underwent prophylactic bilateral mastectomy. Patient presented for elective outpatient reconstruction of the right breast fat grafting harvested from the abdomen. During surgery, became hypoxic, requiring emergent intubation with full support. Patient was evaluated by a chest x-ray which ruled out pneumothorax. In the emergency room, she was hypotensive requiring vasopressors. Patient underwent chest CT with findings for bilateral segmental pulmonary embolism visualized with acute right heart strain with elevated right sided heart pressures and >2:1 ratio of right ventricle size to the left ventricle. She was noted to have a negative hounsfield unit of bilateral thrombi, highly suspicious for fat embolism. Given the lack of treatment options other than supportive care for fat embolism, the patient underwent VA-ECMO emergently as salvage therapy. Bedside transesophageal echocardiogram showed multiple masses in the right ventricle extending into the tricuspid chordae and into the right ventricle with severe dysfunction, largest mass measured up to 1.0 cm in size. Patient was managed with full support of VA-ECMO for a total of seven days before transitioning to mechanical ventilation and decannulation and cardiac support was weaned off. Patient's neurological status was back to baseline post ECMO. Ultimately, patient required a tracheostomy and was discharged to inpatient rehabiliation. DISCUSSION: FES is a systemic disorder with embolization of fat particles causing cytotoxin production and inflammatory state from the free fatty acids resulting in multiorgan dysfunction presenting with tachypnea, tachycardia, fever, possible rash. Pulmonary circulation is affected upto 75% of patients leading to ARDS requiring prolonged mechanical ventilation. Development of fat pulmonary embolism has a significantly high mortality. Treatment with ECMO allows for cardiopulmonary life support with severe respiratory failure bu replacing deoxygenated blood with oxygenated blood. Most commonly noted cases are related to orthopedic surgeries or trauma. To our knowledge, FES as a complication from liposuction requiring VA-ECMO as a successful treatment option has not yet been reported. CONCLUSIONS: Here we present one of the first cases of a successfully treated patient with VA-ECMO who developed florid shock secondary to acute fat embolism syndrome due to an elective breast fat grafting surgery. The important learning to identify is diagnosing fat embolism. REFERENCE #1: https://pubs.asahq.org/anesthesiology/article/89/3/782/36964/Early-Fat-Embolism-after-Liposuction REFERENCE #2: https://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2020.201.1_MeetingAbstracts.A5188 REFERENCE #3: https://pubmed.ncbi.nlm.nih.gov/18509699/ DISCLOSURES: No relevant relationships by Pranav Mahajan, source=Web Response No relevant relationships by TEMITOPE SHODUNKE, source=Web Response No relevant relationships by Abdul Siddiqui, source=Web Response No relevant relationships by Riddhi Upadhyay, source=Web Response