How to reduce the risk of fat embolism during interlocking nail femur surgery?

Reducing Risk of Fat Embolism During Interlocking Nail Femur Surgery

Early surgical stabilization of femoral shaft fractures within 24 hours of injury is strongly recommended to prevent fat embolism syndrome and ARDS.1

Pathophysiology and Risk

Fat embolism syndrome (FES) occurs when fat particles enter the bloodstream during femoral canal instrumentation, causing systemic inflammatory response and potentially serious complications:

• Occurs in approximately 0.5-2.2% of long bone fractures 2
• Can lead to respiratory distress, cognitive dysfunction, and cardiovascular collapse 3
• Particularly concerning during procedures that breach the femoral canal, such as intramedullary nailing 1

Surgical Techniques to Reduce Fat Embolism Risk

Femoral Canal Preparation

• Thoroughly wash and dry the femoral canal before cement or prosthesis insertion 1
• Use a pressurized lavage system to clean endosteal bone of fat and marrow contents 1
• Use a distal suction catheter on top of an intramedullary plug 1
• Avoid excessive manual pressurization in high-risk patients 1

Venting Techniques

• Create venting holes in the femoral cortex to reduce intramedullary pressure 4
• Proximal venting can reduce pressures by up to 70% in the femur 4
• Distal venting can reduce pressures by up to 90% 4

Cement Application (If Used)

• Insert cement from a gun in retrograde fashion on top of the plug 1
• Pull the suction catheter out as soon as it is blocked with cement 1
• Avoid vigorous pressurization of cement in patients at risk of cardiovascular compromise 1

Anesthetic Considerations

Pre-operative Preparation

• Ensure adequate hydration before induction of and during anesthesia 1
• Consider invasive blood pressure monitoring for high-risk patients 1
• Maintain vigilance for cardiovascular events once the femoral head is removed 1

Intra-operative Management

• Maintain systolic blood pressure within 20% of pre-induction values throughout surgery 1
• Use vasopressors and/or fluids as needed to maintain blood pressure 1
• Be prepared for potential cardiovascular collapse with readily available vasopressors (e.g., metaraminol/adrenaline) 1
• Increase inspired oxygen concentration during critical moments of the procedure 1

Communication and Team Approach

• Surgeon should verbally inform the anesthetist before preparing the femoral canal 1
• Anesthetist should confirm awareness of femoral canal preparation 1
• All team members should be aware of the potential for adverse events during femoral instrumentation 1

Post-operative Considerations

• Monitor for signs of fat embolism syndrome for at least 24 hours post-surgery 3
• Administer supplemental oxygen for at least 24 hours postoperatively 1
• Monitor for hypoxia, mental status changes, petechiae, tachycardia, fever, thrombocytopenia, and anemia 3

Important Caveats

• Corticosteroids are NOT recommended for prevention of fat embolism syndrome 5
• High-dose corticosteroids have shown detrimental effects in trauma patients, including increased mortality in traumatic brain injury and increased infection risk in spinal cord injury 1, 5
• Despite using techniques like insertion without reaming, the risk of fat embolization cannot be completely eliminated 6
• The timing of surgical intervention is crucial - early stabilization (within 24 hours) is associated with lower risk of fat embolism 1

By implementing these evidence-based strategies, the risk of fat embolism during interlocking nail femur surgery can be significantly reduced, improving patient outcomes and reducing morbidity and mortality.