Beatriz Rivera Rodriguez, MD,
University of Miami / Jackson Memorial Hospital Internal Medicine Resident
n/a
Disclosure information not submitted.
Robert Flowers, MD, MPH
University of Miami - Jackson Memorial Hospital
Disclosure information not submitted.
Waleed Sneij, MD
Assistant Professor of Clinical Medicine, Division of Pulmonary and Critical Care
University of Miami, United States
Disclosure information not submitted.
João Roberto Breda, MD
Associate Professor of Surgery, Division of Thoracic Transplantation
Miami Transplant Institute / University of Miami, United States
Disclosure information not submitted.
Title: Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) for Macroscopic Fat Embolism
Case Report Body
Introduction: Fat embolism syndrome (FES) most commonly occurs from long bone fractures but has also been described in non-orthopedic trauma and fat grafting. Fat grafting may result in larger particles of fat embolizing into the systemic circulation resulting in vascular obstruction and cardiovascular collapse. This is a clinically distinct syndrome called macroscopic fat embolism (MAFE). Unlike the delayed onset of FES, MAFE often occurs intra-operatively, and mortality approaches 100%. We describe a case of VA-ECMO used with good outcome in a patient with MAFE after gluteal fat grafting.
Description: A 28-year-old woman presented with respiratory failure. She had undergone abdominal liposuction with gluteal fat grafting at an outside facility. After completion of surgery and prior to extubation, the patient became hypotensive, hypoxic, and cyanotic. On arrival to our institution, initial vitals showed a heart rate of 137 and a blood pressure of 93 / 55 mmHg. She was started on norepinephrine. Labs showed arterial pH 6.9, pO2 93, pCO2 108, with bicarbonate 21 mmol/L on venous panel, lactic acid 6.4 mmol/L, and troponin I 0.114 ng/mL. Chest CTA showed fat-attenuation lobar and segmental pulmonary emboli. Point of care ultrasound revealed right ventricular (RV) failure with septal bowing. Vasopressin and inhaled nitric oxide were added, and she was started on renal replacement therapy. The ECMO team was consulted due to worsening hemodynamics and malperfusion despite full supportive measures. After initiation of VA-ECMO, she significantly improved, was decannulated after 6 days of support, and extubated 4 days later. She was discharged after 28 days of hospitalization.
Discussion: Supportive therapies for acute RV failure should be enacted while considering ECMO support. These include providing ionotropic support with dobutamine or epinephrine to improve RV contractility and using inhaled pulmonary vasodilators to reduce RV afterload. Intravenous fluids may worsen a subset of low cardiac output physiologies, as observed in our patient when a push of sodium bicarbonate for severe acidosis acutely worsened her blood pressure. In life-threatening cases of MAFE, ECMO may be beneficial, although its use in MAFE has not been described. This case suggests that early use of VA-ECMO can improve outcomes in this syndrome.