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FAT EMBOLI SYNDROME

IN LIPOSUCTION

Magda

REFERENCES
Grazer FM. Abdominoplasty. In McCarthy JG, editor. McCarthy Plastic Surgery Gordon JB. Liposuction, trunk Available from: http://www.emedicine.com/; March 2006 Kirkland L. Fat Embolism Available from: http://www.emedicine.com/; August 2005 Laub DR. Fat embolism and fat embolism syndrome. In Hetter GP, editor. Lipoplasty 2nd ed. Moser KM. Pulmonary Thromboembolism. In Braunwald E, editor. Harrisons Principle of Internal Medicine 11th ed. Pitman GH. Liposuction and body contouring. In Aston SJ, editor. Grabb and Smiths Plastic Surgery 5th ed. Vistnes MD. Liposuction, large volume: safety and indications Available from: http://www.emedicine.com/; March 2006 2

DEFINITION
Clinical entity characterized by sudden cardiopulmonary & neurological deterioration following precipitating event, usually bone fracture/other trauma to marrow (Laub,1990) fat material, through the circulation obstructs blood flow via a smaller calibre vessel (for ex. stroke, pulmonary embolism, central retinal artery occlusion).
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CAUSES
Blunt trauma (90%) Acute pancreatitis Diabetes mellitus Burns Joint reconstruction Cardiopulmonary bypass Parenteral lipid infusion Sickle cell crisis Liposuction

MORBIDITY/MORTALITY IN LIPOSUCTION/ABDOMINOPLASTY
Grazer & Goldwyn (1977): - 1 in 100 px serious thromboembolic episode - 1 in 1000 px die Patients with increased age, multiple underlying medical problems, and/or decreased physiologic reserves have worse outcomes than other patients.
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Grazer (2000): surveyed 1200 actively practicing aesthetic plastic surgeons in USA, 917 reported from 1994-1997, after 496,245 lipoplasties 95 fatalities mortality rate of 1/5224 ~ < 0.5%. (similar to rates quoted elsewhere.) Pulmonary thromboembolism major cause of death in 23.42.6% of these deaths. Mortality rate of fat emboli generally= 10-20%. (Kirkland 2005)
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PATHOPHYSIOLOGY

Figure 1: (McCarthy)
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I.

Mechanical theory: Large fat droplets venous system deposited in pulmonary capillary beds arteriovenous shunts brain local ischemia & inflammation + release of inflammatory mediators, platelet aggregation & vasoactive amines (Kirkland, 2005).

II. Biochemical theory: Trauma &/or sepsis hormonal changes systemic release of FFA as chylomicrons coalesce due to acute-phase reactants, such as CRP reactions above
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DIAGNOSIS
Gurd: Major Respiratory insufficiency Cerebral involvement Petechial rash Minor Pyrexia Renal changes Tachycardia Jaundice Retinal changes + 1 major + 4 minor + fat macroglobulinemia
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Lindeque et al: Sustained PaO2 < 60 mmHg Sustained PaCO2 > 55 mmHg or pH < 7.3 Sustained RR > 35 X/mnt, after sedation Dyspnea, tachycardia & anxiety + Clinical history + 1 of above criteria

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Clinical
Respiratory consequences: Embolic obstruction cessation of pulmonary capillary blood flow bronchoalveolar hypocapnia ventilated but not perfused lung zoneintrapulmonary deadspace pneumoconstriction: homeostatic mechanism to

wasted ventilation Loss of alveolar surfactant within 2 3 hrs atelectasis within 24 48 hrs

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Hemodynamic consequences: Obstruction pulmonary arterial bed area resistance to pulmonary blood flow pulmonary hypertension R ventricle failure cardiac output

Early persistent tachycardia at onset. AbN heart sounds Fever with high-spiking temperatures.

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Dermatologic

Reddish-brown nonpalpable petechiae:upper

body esp. in axillae; within 24-36 hours; in 20-50%; resolve quickly.


Subconjunctival & oral hemorrhages & petechiae Neurologic: CNS dysfunction: initially as delirium stupor,

seizures, or coma; frequently is unresponsive to correction of hypoxia.


Retinal hemorrhages with intra-arterial fat

globules on funduscopic examination

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Lab Studies
BGA: An otherwise unexplained in pulmonary shunt fraction alveolar-to-arterial O2 tension difference, esp within 24-48 hrs. Thrombocytopenia, anemia & hypofibrinogenemia, yet nonspecific. Urinary fat stains, not specific enough. Fat globules in urine : common after trauma. Preliminary studies of cytology of pulmonary

capillary blood from wedged pulmonary a. catheter fat globules in px with FES 14

Imaging studies
Chest X-rays: diffuse bilat interstitial/alveolar infiltrates (Snow storm pattern) within 24-48 hours of onset. Noncontrast head CT: may be N / reveal diffuse whitematter petechial hemorrhages ~ microvascular injury. Helical chest CT: may be N / parenchymal changes ~ lung contusion, ALI/ ARDS.
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Nuclear medicine ventilation/perfusion imaging of the lungs: may be N / show subsegmental perfusion defects.

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MRI: in 1 small study, multiple, nonconfluent, hyperintense lesions. Transcranial Doppler sonography: In small study, 5 px with trauma monitored with intracranial Doppler sonography, 2 during intraop nailing of long bone fractures Cerebral microembolic signals detected up to 4 days after injury. Transesophageal echocardiography (TEE): evaluates intraop release of marrow contents into the bloodstream during intramedullary nailing. Density of echogenic material passing via R side of heart ~ degree of in SaO2.
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DIFFERENTIAL DIAGNOSIS
Hypervolemia Pulmonary contusion Cardiogenic pulmonary edema Aspiration pneumonia ARDS due to hypovolemic shock

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PREVENTION
5 Pillars of safety in liposuction 1) Surgeon: properly trained & knowledgeable in liposuction technique 2) Anesthesiologist: well trained & have complete understanding of physiology ~ with infusion & removal of large fluids volumes. 3) Facility: completely equipped 4) Support staff: thoroughly trained. 5) Patient: selected appropriately for procedure.
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Patient Selection
In either American Society of Anesthesiologists (ASA) class I (healthy with no medical problems) or ASA class II (medical problems well controlled on medications). Weight: stable or decreasing with diet & exercise. Px with rapid or persistent weight gain are started on a program of exercise & nutrition.

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Evarts et al (1976), Peltier (1971), Grazer (1990): 5% Dex & 5% alcohol (total 50 gr alcohol), IV, in 30 min 3 hrs, at start of abdominoplasty 80 mg/100cc blood level Alcohol: - Prevents breakdown of released fat FFA - Stimulates tissue plasminogen activator & prostacyclin : @ antiplatelet activity, @ antithromboembolic activity, @ vasodilator
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Corticosteroids:
Several studies varying results, usually with methylprednisolone, in patients identified at high risk Optimal timing, duration & dose: undetermined.

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Anesthetic and Fluid Management


General endotracheal anesthesia for large vol liposuction. Intraop monitoring: blood pressure, ECG, pulse oximetry, temperature, end-tidal CO2, urine output, fluid balance. Continuous communication between surgeon & anesthesiologist provided with running balance of wetting solution infused, fat & saline aspirated, blood loss & urine output.

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Fluid balance uses residual vol theory. Residual vol: Total fluids received (IV fluid + crystalloid wetting sol) [saline portion of aspirate (without fat) + urine output]. residual crystalloid vol remaining in px as fluid resuscitation source in postop period (Vistnes MD,2006) Divide this no by preop weight in kg value in cm3/ kg. This no usually is 90-120 mL/kg no signs of intravascular vol depletion or overload.
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IV fluid usually unnecessary because large vol of sc. inj gradually absorbed Subcutaneous crystalloid inj vol = 2 X aspirate vol Total fluid replacement Total/near-total fluid replenishment (Grabb).

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Surgical Technique
4 techniques: Dry No fluid injected into subcutaneous fat layer. 25-45% of aspirated vol is blood. not used commonly except for small vol suctions. Wet (Illouz, 1980s) Infusion of 100-300 cm3 of saline into each site of fat to be removed . aspirated blood vol to 20-25% of total aspirate. Addition of 1:200,000 or 1:400,000 epinephrine to fluid (Hettler,1983) < 15% of aspirate was blood.
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Superwet (late 1980s): infusion of fluid containing epinephrine & low dose local anesthetic in 1:1 ratio to vol of expected aspirate. Blood loss was 2% of aspirated vol. Tumescent (Klein, 1990) Large vol of saline + 1:1,000,000 epinephrine + 0.05% lidocaine injected sc. to tense tissues. injected fluid vol > that expected to be suctioned. Blood loss 1% of aspirated volume.
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Post operative care


Close monitoring: pulse oximetry, hemodynamics, pulmonary function & fluid vol status + control of postop pain & nausea. Ambulation as soon as possible & lower extremity muscle-contracting exercises while in bed to risk of deep venous thrombosis & pulmonary embolus. Compressive postoperative garment fluid sequestration into tissues, as access incisions are closed to prevent wound drainage.
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THERAPY
Supportive respiratory care Supportive medical care Methylprednisolone

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PROGNOSIS
Mild to coma & death Has improved in 30 yrs, from 15 20% mortality rare today due to improved supportive tx Depends on pxs respiratory function > severe in px with pulmonary disease or shock As in ARDS, pulmonary sequelae usually resolve almost completely within 1 yr.
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Neurological changes: almost always reversible in days or weeks Residual neurologic deficits: nonexistent subtle personality changes memory & cognitive dysfunction long-term focal deficits.
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CONCLUSION
Incidence of subclinical fat embolization post liposuction unknown Common to clinical fat emboli syndrome: inadequate blood & fluid replacement, pulmonary pathology, obesity, systemic illness Appropriate px selection, limited resection size, aggressive postop blood, fluid & lung management greatly incidence
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KEMATIAN PADA LIPOSUCTION (Juanda E) Kematian dapat terjadi pada setiap pembedahan, termasuk liposuction. Sebab utama adalah anesthetic death (terutama bius total) , thromboemboli dan keadaan umum (membuang terlalu banyak lemak dalam satu saat). Yang menarik, angka kematian pasca liposuction pada tahun 1999 di Amerika Serikat adalah: angka kematian liposuction yang dilakukan para anggota American Society of Plastic and Reconstructive Surgeons (ASPRS) adalah 1:5000; bandingkan dengan angka kematian anggota American Academy of Cosmetic Surgery (AACS= perkumpulan bedah kosmetik multi disiplin) adalah 1:40.000. Berarti angka kematian yang dilakukan anggota ASPRS adalah 8 kali lebih besar (8). Dalam perkembangannya, ASPRS juga menganjurkan anggotanya menggunakan tumescent anesthesia , sehingga angka kematian pasien

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