title: Cerebral fat emboli: a trigger of post-operative delirium.
abstract: Accumulating evidence implicates cerebral fat embolism (CFE) as a causative agent in post-operative confusion (POC). CFE occurs following orthopaedic procedures including, intra-medullary (IM) nailing and total joint arthroplasty (TJA). The incidence of CFE is high (59-100% TJA) and the resulting POC is associated with higher overall complication rates. Cognitive dysfunction improves in many patients but can persist - with potentially disastrous outcomes. The pathomechanics of CFE implicate circulating lipid micro-emboli (LME) that are forced from IM depots by instrumentation/nailing. Passage to the left side of the heart is possible through intra-cardiac or arteriovenous shunts in the lung. LME are propelled to the brain where they cause disruption via ischemia or by alterations in the blood-brain-barrier - causing cerebral oedema. Prevention of CFE follows established practices for preventing FES and consideration of additional techniques to remove resident fat and reduce IM pressures. When CFE occurs supportive treatment should be established.
authors.affiliation: Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds, UK.
authors.forename: George
authors.initials: G
authors.lastname: Cox
authors.forename: Christopher
authors.initials: C
authors.lastname: Tzioupis
authors.forename: Giorgio Maria
authors.initials: GM
authors.lastname: Calori
authors.forename: James
authors.initials: J
authors.lastname: Green
authors.forename: David
authors.initials: D
authors.lastname: Seligson
authors.forename: Peter V
authors.initials: PV
authors.lastname: Giannoudis
mesh_terms: D001178:Arthroplasty / Q000009:adverse effects; D001812:Blood-Brain Barrier / Q000503:physiopathology; D002545:Brain Ischemia / Q000209:etiology; D003221:Confusion / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control; D003693:Delirium / Q000209:etiology*; D004620:Embolism, Fat / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control; D005594:Fracture Fixation, Intramedullary / Q000009:adverse effects* / Q000379:methods; D006801:Humans; D020766:Intracranial Embolism / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control; D011184:Postoperative Period; D011655:Pulmonary Embolism / Q000209:etiology