An 87‐year‐old woman underwent internal fixation for a right femoral neck fracture under general anesthesia. Intraoperatively, she developed sudden hypoxemia, shock, and severe right ventricular dilatation, necessitating the introduction of venoarterial extracorporeal membrane oxygenation. Pulmonary thromboembolism was excluded by dedicated computed tomography pulmonary angiography (Figure 1A,B).
FIGURE 1.
Pulmonary thromboembolism was excluded by dedicated computed tomography pulmonary angiography (A, B). Twelve hours postoperatively, conjunctival petechiae appeared (C, white arrow). Brain magnetic resonance imaging after 5 weeks revealed diffuse small, low‐signal spots (starfield pattern) on susceptibility‐weighted imaging (D, yellow arrow heads).
Twelve hours postoperatively, conjunctival petechiae appeared (Figure 1C, white arrow). Brain magnetic resonance imaging after 5 weeks revealed diffuse small, low‐signal spots (starfield pattern) on susceptibility‐weighted imaging (Figure 1D, yellow arrow heads), confirming the clinical diagnosis of fulminant fat embolism syndrome (FES).
Although the classical FES triad (respiratory distress, neurological abnormalities, and petechial rash) is well recognized, it is frequently incomplete or absent at presentation [1, 2]. Especially, fulminant FES can manifest as sudden cardiovascular collapse, which may precede these classical features [3]. Notably, while FES is classically associated with younger patients, it also peaks in the elderly sustaining proximal femoral fractures [4]. During instrumentation, high intramedullary pressure forces marrow fat into the venous system [1, 3]; in elderly patients with reduced cardiopulmonary reserve, this leads to acute right heart failure [2, 3, 4].
This case highlights that FES should be considered in elderly patients presenting with unexplained acute right heart failure during orthopedic surgery.
Funding
The authors have nothing to report.
Ethics Statement
The patient's daughter gave written consent for the publication of this report. Ethics approval for this case report was waived by the Institutional Review Board of our Institution.
Consent
The patient's daughter gave written consent for the publication of this report.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
We would like to thank Dr. Mitsuru Doi for his support in patient care and Editage (www.editage.jp) for English language editing.
Data Availability Statement
Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
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Associated Data
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Data Availability Statement
Data sharing not applicable to this article as no datasets were generated or analysed during the current study.