Early, reliable, utilitarian predictive factors for fat embolism syndrome in polytrauma patients

Gopinathan, Nirmal Raj; Sen, Ramesh Kumar; Viswanathan, Vibhu Krishnan; Aggarwal, Amit; Mallikarjun, H C; Manoharan, Sakthivel Rajan Rajaram; Sament, Radheshyam; Kumar, Avinash

doi:10.4103/0972-5229.112155

Cited by 5 publications

(3 citation statements)

References 30 publications

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“…Intramedullary nailing of the femur often leads to bone marrow emboli, but only occasionally causes fat embolism syndrome ( 42 – 44 ). Identifying risk factors including polytrauma, high lactate levels, and early oxygenation failure therefore becomes crucial ( 45 ). Further, the combined effects of multiple traumas and total embolic load likely increases risk of fat embolism syndrome.…”

Section: Discussionmentioning

confidence: 99%

Femoral nailing associated with bone marrow emboli in pigs induced a specific increase in blood IL-6 and broad inflammatory responses in the heart and lungs

Kristiansen,

Storm,

Emblem

et al. 2024

Front. Immunol.

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IntroductionBone marrow embolization may complicate orthopedic surgery, potentially causing fat embolism syndrome. The inflammatory potential of bone marrow emboli is unclear. We aimed to investigate the inflammatory response to femoral intramedullary nailing, specifically the systemic inflammatory effects in plasma, and local tissue responses. Additionally, the plasma response was compared to that following intravenous injection of autologous bone marrow.MethodsTwelve pigs underwent femoral nailing (previously shown to have fat emboli in lung and heart), four received intravenous bone marrow, and four served as sham controls. Blood samples were collected hourly and tissue samples postmortem. Additionally, we incubated bone marrow and blood, separately and in combination, from six pigs in vitro. Complement activation was detected by C3a and the terminal C5b-9 complement complex (TCC), and the cytokines TNF, IL-1β, IL-6 and IL-10 as well as the thrombin-antithrombin complexes (TAT) were all measured using enzyme-immunoassays.ResultsAfter nailing, plasma IL-6 rose 21-fold, compared to a 4-fold rise in sham (p=0.0004). No plasma differences in the rest of the inflammatory markers were noted across groups. However, nailing yielded 2-3-times higher C3a, TCC, TNF, IL-1β and IL-10 in lung tissue compared to sham (p<0.0001-0.03). Similarly, heart tissue exhibited 2-times higher TCC and IL-1β compared to sham (p<0.0001-0.03). Intravenous bone marrow yielded 8-times higher TAT than sham at 30 minutes (p<0.0001). In vitro, incubation of bone marrow for four hours resulted in 95-times higher IL-6 compared to whole blood (p=0.03).DiscussionA selective increase in plasma IL-6 was observed following femoral nailing, whereas lung and heart tissues revealed a broad local inflammatory response not reflected systemically. In vitro experiments may imply bone marrow to be the primary IL-6 source.

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Section: Discussionmentioning

confidence: 99%

Femoral nailing associated with bone marrow emboli in pigs induced a specific increase in blood IL-6 and broad inflammatory responses in the heart and lungs

Kristiansen,

Storm,

Emblem

et al. 2024

Front. Immunol.

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“…There is no single laboratory test which is diagnostic of FES. Hence this requires early diagnosis and treatment, there is importance in knowing the risk factors [20] . Risk factors for fat embolism are male patient, young patient, closed fracture, intramedullary nailing and conservative management of long bone fractures [8,21] .…”

Section: Discussionmentioning

confidence: 99%

“…Risk factors for fat embolism are male patient, young patient, closed fracture, intramedullary nailing and conservative management of long bone fractures [8,21] . According to a study by Gopinathan et al [20] , the predictors of fat embloism were NISS score, serum lactate level at time of admission and hypoxaemia. However this study has included patients only with polytrauma.…”

Section: Discussionmentioning

confidence: 99%

Fat embolism Syndrome: Is it common in smokers

Kumar¹,

Nidhiry²,

Juneid³

et al. 2021

Nat. J. Clin. Orthop.

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Introduction: Diagnosis of Fat Embolism Syndrome (FES) depends mainly on clinical features and there are no diagnostic laboratory tests available. In spite of so many advancements in the management of long bone fractures, management of FES is mainly supportive. Patients who are prone to develop FES are to be carefully screened as a part of pre-operative work up in order to prevent the complications later. There are very few studies which establish the risk factors associated with fat embolism. Materials and methods: 26 Orthopaedic trauma patients who were diagnosed with fat embolism syndrome according to Gurd and Wilson criteria and Schonfeld's FES index, and as per inclusionexclusion criteria of the study were included. All demographic data, bone involved, type of fracture, timing and type of surgery was noted and data regarding their smoking status was taken into consideration. Observation: Out of 26 patients of FES, 25 were male and 1 was female. Mean age was 27.1 years. 11 were fractures of Femur and 15 were fractures of Tibia, 4 patients had multiple fractures. There were 5 cases of open fractures. Among the 26 patients who developed FES, 80.7% of them were cigarette smokers and all of them were male patients. Conclusion: It is our observation that among the patients who developed FES, 80.7% were cigarette smokers. Though this study does not establish a direct causal relationship between smoking and FES which requires further detailed analytical studies, there appears to be an association between FES and cigarette smoking. Hence, we conclude that smokers are prone to develop FES.

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Can IL-6 predict the development of fat embolism in polytrauma? A rabbit model pilot experimental study

Subramanian

Sen

Gopinathan

et al. 2020

Journal of Clinical Orthopaedics and Trauma

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Background: There are few studies in the literature that correlates the level of IL-6 with fat embolism syndrome (FES). But there is no conclusive correlative evidence of its specific relation to the establishment of FES. Also it is a proven fact that polytrauma due to its associated multiple long bone fracture and/ or associated shock can predispose an individual to FES. By hypothesizing that polytrauma induces Fat Embolism in the animal; it was considered worthwhile to study the association of IL-6 in polytrauma induced Fat Embolism (FE) and to compare it with induced FE by injecting fatty acids in rabbits. Materials and methods: An animal study was conducted in 32 New Zealand white rabbits. The animals were divided into 3 groups: control, fat embolism and polytrauma group. We injected 6 ml of normal saline and 0.2 ml of linoleic acid in the control and fat embolism group respectively. In the polytauma group we created bilateral femur and tibial shaft factures which were stabilized with intramedullary Kwires. Blood was taken before and at 6, 12 and 24 h after the procedure to measure plasma IL-6 levels. The rabbits were euthanized at 24 h and lungs were removed and stained for fat globules. Results: All rabbits in the fat embolism group and around 72.22% rabbits in polytrauma group had fat embolism. The IL-6 levels were raised in all the groups reaching a peak at 6 h after procedure with a decline in the values at 12 h for polytrauma and fat embolism group. IL-6 in the control group was stationary after an initial raise at 6 h. There was no statistically significant difference seen among the groups (p value > 0.05) at 6 h. Conclusion: IL-6 is not a specific marker to fat embolism per se or polytrauma who later develop complications like FES. Even though the recent literature says that IL-6 is an early marker of fat embolism, still the diagnosis of fat embolism syndrome is clinical only and can be supplemented by laboratory markers. None of the laboratory markers individually is good enough to predict the development of FES in an individual.

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Early, reliable, utilitarian predictive factors for fat embolism syndrome in polytrauma patients

Cited by 5 publications

References 30 publications

Femoral nailing associated with bone marrow emboli in pigs induced a specific increase in blood IL-6 and broad inflammatory responses in the heart and lungs

Femoral nailing associated with bone marrow emboli in pigs induced a specific increase in blood IL-6 and broad inflammatory responses in the heart and lungs

Fat embolism Syndrome: Is it common in smokers

Can IL-6 predict the development of fat embolism in polytrauma? A rabbit model pilot experimental study

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