S??????? ???O???S ??????S

1
S??????? ???O???S ??????S

• ?.G????????, ?.?????????S

2
???O??S ?????? ???F???? ?GG??O? ??? ????SF?????
????????? 10-40 µm.S??????? ???O???S ??????S
??????O??? ???O?? ?????? S??????????? ???
???????S ?????OS??S ??? ??G?S???????
????????.????G??F??? ??O?? F??? ?? 1862 ??? ???
ZENKER , S? ????????????? ?e???t?µ? ap?f?a??
t?? t????e?d?? t?? p?e?µ???? µe ??p?sfa???a.

• 
  

3
Lower, p??? 330 ?????a ??????se e?d?f??ß?a ???a
se s??????- ??p?d?? eµß???

• Magendie, 19 a???a
• ???a???? ap?f?a?? µ????? a??e???
• ap? ??p?sfa???a µet? iv ??????s?
• e?a???
• Virchow ??????s? e?a??? iv p?????ese
• p?e?µ????? ??d?µa.

4
??T?G?????- 2 T?O???S

• Gauss, 1916- ???????? ???? t?? e???a?st??
  f?eß???? ???p?? t?? µ?e??? t?? µa???? ?st??
  a???s? t?? e?d?µ?e????? p?es?? ? ?p??a d?a t??
  ap??ete?t???? f?eß?? µetaf??eta? sta p?e?µ?????
  t????e?d? ap?f?a?? t?? t????e?d?? ap? ??p??
• Peltier(1950,1952) solid versus hollow nails,
  driving the nail in slowly with a pause between
  hammer blows

5
Lehmann,1922 ??????????

• ??p?? µetaf??eta? sta t????e?d? t?? p?e?µ??????
  ?a? s?st?µat???? ?????f???a? ?p? µ??f? TGC
  e??µ??a µe sfa????e? ? LDL ?? ????µ????(lt1µm).
• ?ate???aµ??e? LPL ap?sta?e??p???s? t??
  ????µ????? ??pa?? ???a p?? ?p? t?? ep?d?as?
  t?? CRP e?????ta? se µe?a??te?a sfa???d?a(gt20µ)
  t????? ß??ß? p?e?µ?????? e?d???????, ????s?
  ???µß?p?ast???? ape?e?????s?
  a??e??s?spast???? ??s???, s?ss??e?s?
  a?µ?peta????? , DIC fa???? ??????

6
???????S??

• ARDS
• ??ata?a??? e??efa????? ?e?t?????a?
• ?e?µat???? ß??ße?-pet??e?e?

7
????? ???O???S ??????S

• ?????????? gt90
• ?at??µata µa???? ?st?? ?a? p?????- ?ea???
  p???t?a?µat?e?
• ?at??µata ?s????- ?t?µa gt60 et??
• ?? ??????????
• ?a???eat?t?da, a???????? ?pat?p??e?a,
  e????µat?d?? ?????, ?ste?µ?e??t?da, sa??a??d??
  d?aß?t??, ???se?? d?epa????tta????? a?a?µ?a?,
  e??s?µat??? ?????f???a, pa?atetaµ??? ???s?
  ???t???e?d??, e???se?? ??p?d?? d?a??µ?t??
  pa?e?te???? s?t?s?.

8
???a a?t?a

• ??p?a?a???f?s?, ?pat??? t?a?µa, ßa???
  e??a?µata,???a????? s?µp??se??, d?aµpe??? t?a?µa
  µe s???d? ?at??µata

9
??????????G??

• Gurd-1974. 67 t?? t?a?µat??? ????? s?µpt?µata ?
  s?µe?a ??p?d??? eµß???? ????? ??p?sfa???a st??
  s?st?µat??? ?????f???a ?a? 19 s?ßa?? t?a?µat???
  e?d??????? t? s??d??µ?
• Pell et al, 1993 The detection of fat embolism
  by TEEC during reamed intramedullary nailing.
• A study of 24 patients with femoral and
  tibial fractures. J Bone Joint Surg Br
  75(6)921-925
• ??????sa? t? s??d??µ? se 12.5
• Bulger-1997-a?ad??µ??? µe??t? 10 et??.
  S????t?ta s??d??µ?? ??p?d??? eµß???? se as?e?e??
  µe ?at??µata µa???? ?st?? 0.9 (27 ap? t??? 3026
  as?e?e?? p?? µe?et????a? e?d???sa? t? s??d??µ?
  s?µf??a µe ta ???t???a t?? Gurd)

10
???G?OS?

• ????? p?s?st? ?p???a? !
• ?e? ?p???e? pa?????µ????? e??tas?

11
Gurds Criteria

• FES 1 major 4 minor fat microglobulinemia

Major features Minor features
Petechial rash Tachycardiagt 120 /min
Respiratory symptoms plus bilateral signs with positive radiographic changes Pyrexia gt 39.4 ?
Respiratory symptoms plus bilateral signs with positive radiographic changes Retinal fat or petechiae
Respiratory symptoms plus bilateral signs with positive radiographic changes Urinary fat globules or oligoanuria
Respiratory symptoms plus bilateral signs with positive radiographic changes Sudden drop in Hb level gt 20
Cerebral signs unrelated to head injury Sudden thrombocytopenia gt 50
Cerebral signs unrelated to head injury High ESR gt 71 mm/h
12
?????????- ????????? ????G?????? ?O?
????????G??O? ???????O?

• ??G RBBB
• CT (high resolution)
• MRI
• BAL?
• ?????a ?ef??? ?a? d??µat?? ??p?sfa???a se
  s??d?asµ? µe µ?????µf?a?ta

13

• ???a e??ast???a?? e???µata
• - ????s? t?? LPL 5-8 µ??e? µet?, ?ta? ? e????a
  a????e? ?a ?p????e?
• - ????s? FDP, pa??tas? aPTT, PT
• - ?pasßa?st?a?µ?a, ?pe???p?da?µ?a

14
Schonfeld Fat Embolism Index

• FES 5 or more points

Points
Diffuse petechiae 5
Alveolar infiltrates 4
Hypoxemia (lt 70 mmHg) 3
Confusion 1
Fever gt 38 ? 1
Heart rate gt 120 /min 1
Respiratory rate gt 30 /min 1
15
Lindeques Criteria

• FES femur fracture tibia fracture 1 feature

A sustained PaO2 lt 8 kPa (60 mmHg)
A sustained PaCO2 gt 7.3 kPa (55 mmHg) or pH lt 7.3
A sustained respiratory rate gt 35 /min even after adequate sedation
Increased work of breathing judged by dyspnea, use of accessory muscles, tachycardia and anxiety
16
T???????

• ???a??? sta?e??p???s? t?? ?ata?µ?t??
• ??ap?e?st??? ?p?st?????
• ?p??at?stas? ?????f?????t?? a?µat??- a?µ?d??aµ???
  ?p?st?????

17
??????

• 90-95, ap??at?stas? t?? ß?aß?? se 2-3 ßd?µ?de?
• T??t?t?ta 5-10

18

• ?a?d?? µe ?at??µata µa???? ?st??- s????t?ta
  s??d??µ?? ??p?d??? eµß???? 0.05
• ???t???a t?? Weisz
• 1. ?µß??a aµf?ß??st??e?d???
• 2. ?et??? ß????a d??µat??, ?ef???,
  p?e?µ????
• 3. ?st??????? e???µata ap? t? ?e???t?µ?
• ??????s?- 1 ap? ta 3 ???t???a

19
?????S??S? ????S???????

• ???e? 23 et?? µetaf??eta? sta ??? ?at?p??
  t???a??? at???µat??
• GCS15/15, ??150/90, ?S120/min,
  ??GF?eß???µß??? ta???a?d?a
• ??t?????????? ??e???? S??t??pt??? ??ta?µa ???
  t??t?µ????? µ???a???(??), ??ta?µa
  p??a???a?p????(?e), ??ta?µa ??t? ??????
• ??t?????af?a ???a??? ????? pa???????? e???µata

20

• ??aµ??st??? ?st????? e?e??e??
• ??µat???????? ?a? ß????µ???? ??e???? ?????
  pa???????? e???µata p??? CPK 1120
• Fraxiparine 0.4 mg ?p?d?????.
• ?d??????e st? ?e??????e?? ?p?? ?peß???? se
  t?p???t?s? e?d?µ?e????? ???? (??) µ???a?? ?a?
  ta?t?????a ?ste?s???es? ?at??µat?? t?? ??t?
  ??????.
• ?????e?a 3 ??e? ?a? 15 ?epta.

21
??sa????S?????????????? 100mg,Fa??ta???? 200µg,
??d??a??? 40mg, ???p?f??? 200mg, at?a?????? 14mg

• ??at???s? ???p?f??? 1 ?a? ?eµ?fa??ta???? se
  t?t??p???µ??e? d?se?? st??d?? iv. FiO2 0.5
• ??e??e???t??? monitiring??G(V5), SpO2, etCO2,
  epeµßat??? µ?t??s? a?t???a??? p?es??, ???a?a
  d?????s?, d???s?f??e?a ?e?µ?µ?t??s?.
• ???? 3.5 Lt ???sta???e?d?, 3 RBC
• ?f?p??s?, a????sa ??F, a?µ?d?µaµ??? sta?e???,
  SpO2 99-100(MV 0.4), ???µ??e?µ????, ???st?
  ep????????a.

22

• ??? ??e? µet? a?f??d?a ??a???
• d?sp???a?, ta??p???a?, a??a?? ep?p?d??
• s??e?d?s??, d???e?s?.
• ?p??tas? (S??160-180mmHg),
• ta???a?d?a(130-150/min).
• ?etaf??? st? ??T, d?as?????s?,
• ???.

23
????a a?µat??

• ??e??e???t??? p??? ?a?? a?ta??a??
• ???? t? d?as?????s? pH 6.94, pCO2 21mmHg, pO2
  51mmHg
• ?????????-?????????
• ???ta a???a ?p? ???(FiO2 100 TV 570ml,
  RR12/min, PEEP6) pH7.OO, pCO2 23mmHg,
• pO2 57mmHg, HCO3 11mmol/l
  

24
??G?S???????S ???G??S

• Hct 33.4, Hb 9.3g/dl, INR1.23, aPTT 37.8,
  WBC 16.000(82/12), PLT107.000, CK 1980, CK-MB
  52, LDH 680.
• ??G, ECHO ??d?? pa????????.
• A?t?????af?a ???a??? ßaµßa??e?de?? s???se?? sta
  ??t? p?e?µ????? ped?a.
• CT e??ef???? µ???? ?p?p???? pe????? (a?)
  ß?e?µat???.

25
?e?te?? µ??a ??s??e?a?

• ?µp??et? -38.9 C
• ?et??e?e? st? ???a???? pe????? ????e? t?? ?????,
  st??? ?µ??? ?a? ep?pef???te?.
• ??????? ?a? a?t????????? e????a ARDS

26
?GOG? p?? a??????????e t?? aµ?s?? ep?µe?e? µ??e?

• ???S?????????, µe S???? t?? e?asf???s? ?a???
  ?st???? ???????s?? ?a? ?????f?????t?? ?????
  a?µat??. ??ap?e?st??? ?p?st????? µe
  ????? FiO2, TV 6ml/kg, RR 20/min, PEEP 10
  ??µ?d??aµ??? ?p?st?????
  µe t?t??p???µ??? st??d?? ????s? ???ad?e?a?????
  (8-12 µg/kg/min)

27
Stad?a?? ße?t??s? t?? ???????? ?a? e??ast???a???
e????a?

• ?p?s?????s? t? 13 ? µ??a.
• ???d?? ap? t? ??T µet? 48 ??e? µe ???st?
  ?e????????? e????a ?a? ap??at?stas? t??
  a?t?????????? e????a? t?? p?e?µ????.

28
?ta? ? ??????s? µ??µat?? ???p?f????- ??d??a????
ep?p??s?et?? a?t???????? pa?????ta? p?????s?? t??
S??

• ? ??????s? ??d??a????- p??p?f???? ??e? ??
  ap?t??esµa t? s?????e?s? ??p?sfa???d??? p??
  te???? e??a? eµfa?? ?? ?e????st? st??ß?da.
• ??a????? t?? d?s?? t?? ??d??a???? ?a? t?? ??????
  p?? µes??aße? ap? t?? pa?as?e?? µ???? t?
  ??????s?, ? s??d?asµ?? µp??e? ?a ap?te?e?
  pa?????ta ???d???? p?????s?? p?e?µ?????? eµß????.
  
• Physicochemical compatibility of propofol
  lidocaine mixture. Anesth Analg 2003971646-51

29
Table 2. Mean Diameters (µm) of the Maximum Oil
Droplets in 10 Randomly Selected Fields of
Propofol-Lidocaine Mixtures


0 10 20 30 1 h 3 h 6 h 24 h
0.5 1 mL (5 mg) 1.5 0.5 1.3 0.3 1.5 0.4 1.5 0.3 1.6 0.5 1.5 0.3 1.5 0.3 1.6 0.4
1.0 1 mL (10 mg) 1.6 0.9 1.5 0.4 1.3 0.1 1.6 0.5 1.7 0.7 1.9 0.3 2.0 0.6 2.1 0.7
2.0 1 mL (20 mg) 1.3 0.4 1.4 0.3 1.4 0.5 1.4 0.5 1.7 0.3 1.7 0.3 2.0 1.2 4.1 2.0
2.0 2 mL (40 mg) 1.4 0.5 1.8 0.7 2.0 1.0 2.4 1.2 3.6 0.8 5.0 1.5 5.3 1.1 9.5 4.0

Values are mean SD. P lt 0.05 versus Time 0. Values are mean SD. P lt 0.05 versus Time 0. Values are mean SD. P lt 0.05 versus Time 0. Values are mean SD. P lt 0.05 versus Time 0. Values are mean SD. P lt 0.05 versus Time 0. Values are mean SD. P lt 0.05 versus Time 0. Values are mean SD. P lt 0.05 versus Time 0. Values are mean SD. P lt 0.05 versus Time 0. Values are mean SD. P lt 0.05 versus Time 0.


30
Figure 2. Scanning electron microscopy (SEM)
micrographs of control background (panel A,
7500x), 1 propofol alone (panel B, 7500x), and
oil droplets at 30 min (panel C, 7500x) and 24 h
(panel D, 5000x) after the addition of lidocaine
40 mg to 20 mL of 1 propofol
Masaki, Y. et al. Anesth Analg 2003971646-1651
31
??????????? S??????? ???O???S ??????S

• ?p?f?a?? t?? p?e?µ?????? ?????f???a? ap? µa????
  ape?e?????s? ??p??? de??? ?a?d?a??
  a?ep???e?a, p?e?µ????? ?p??tas? ?a?at?f???
• ? a???µ??? p?es? st? de??? ???p? ??e?
  ?atast??f???? s???pe?e? se as?e?e?? a????t?
  ??e?d?? t??µa

32
A case of fatal paradoxical fat embolism syndrome
detected by intraoperative TEEC.
Anesth Analg 200192688-89

• -???e?, 30 et?? ??e?st? ??ta?µa
• µ???a???(?e)- e?d?µ?e???? ???s?
• -??e??e???t???, TEEC
• -?ete??e???t???, as?e??? se ??µa
• -CT ??e????, 3 ??e? µet? t? ?e??????e??,
  a???t????
• 8 ??e? µet?, e?tetaµ??? ??d?µa ?a? sta d??
  e??efa???? ?µ?sfa???a

33
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34
Fulminating fat embolism syndrome caused by
paradoxical embolism through a patent foramen
ovale Pell et al. (1993)
NEMJ 329926-929

• ???e? 79 et??, ??e?st? ??ta?µa µ???a???(?e)
• ?p?t???a?t???? ??ta?µa p?? d?et?a?
• ??? p?? ?t???
• ?????aµµat?sµ??? ?e??????e?? 11 µ??e? µet?
• ?e?a???ß??? S??

35
(No Transcript)
36
(No Transcript)
37
(No Transcript)
38
Endovascular closure of a patent foramen ovale in
the fat embolism syndrome. Forteza
et al. ARCH NEUROL(2002) 59455-459

• Ka??µe???? ?ata??af? µ????eµß?????? s?µ?t?? µe
  d?a??a??a?? Doppler
• H s????e?s? t?? ???d??? t??µat?? p????????e t??
  ?e?????????? ap??at?stas?? t?? µ???a???

39
(No Transcript)
40
??????G??F??

• Gurd AR et al (1974) The fat embolism syndrome. J
  Bone Joint Surg Br 56B(3)408-416
• Glover P, Worthley LIG. Fat embolism. Critical
  Care and Resuscitation 19991276-284
• Talbot M, Schemitsch EH. Fat embolism syndrome
  history, definition, epidemiology. Injury, Int.
  J. Care Injured (2006)373-7