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Statistical Analysis and Methodological Considerations (Table 2). The incidence of fat embolism syndrome in Relative risk and 95% confidence intervals (CI) were calculated Am J Med Sci 2008;336:472-7 patients with joint replacement of the lower extrem- using calculator for confidence intervals of relative risk (www. ity, arthroplasty and repair of shoulder or elbow, sign.ac.uk/methodology/risk.xls). bone graft, limb shortening, limb lengthening, os-1979-2005年の米国の入院患者の0.004%がFES Results teotomy, and spinal fusion were too low to calculate accurately. From 1979 through 2005 among 928,324,000 pa- Nonorthopedic conditions including decompres- tients discharged from short-stay hospitals, 41,000 sion sickness, third degree burns, bone marrow transplantation, crushing injury (excluding frac- 大 骨, 頸骨, 腓骨, 骨盤, 肋骨, 上腕骨, 橈骨, 尺骨 (0.004%) had fat embolism syndrome. The incidence of fat embolism remained relatively unchanged over ture), pancreatitis, diabetes mellitus, panniculitis, the interval of study (Table 1). Among 23,829,000 fatty liver, and sickle cell anemia were either not 上記いづれかの単独骨折患者の0.12%でFESを合併. patients with isolated or multiple fractures involv- accompanied by fat embolism syndrome or only rarely, and the incidences were too low to calculate ing the femur (any site), tibia, fibula, pelvis, ribs, accurately. 多発骨折を含むと0.17%でFESを合併. humerus, radius, or ulna, 41,000 (0.17%) developed fat embolism syndrome. The fracture site most fre- The fat embolism syndrome was more frequent in quently responsible for fat embolism was the femur men (relative risk 5.71) (Table 3). A higher propor- (Figure 1). The incidence of fat embolism was higher tion of men had fractures of the femur (excluding in patients with multiple fractures of these sites neck), tibia or fibula than women (25% versus 14%), FES患者の骨折の種類, 頻度; [16,000 of 2,291,000 (0.70%)] than in patients with and fewer men had isolated fractures of the neck of the femur (24%) than women (45%). Fractures of the isolated fractures of these sites [25,000 of 21,538,000 (0.12%) (P Ͻ 0.0001)]. pelvis, ribs, humerus radius, or ulna occurred in Among 388,000 patients with multiple fractures 51% of men and 41% of women. 大 骨骨幹部骨折が最多.次いで頸骨, 腓骨. that included the femur (excluding neck), 1.29% had fat embolism syndrome (Table 2). Among 1,643,000 Among 1,178,000 patients aged 0 to 9 years who had isolated fractures of the femur (any site), tibia, 40 頚部骨折は頻度は低いが, 34 全体では17%を占める Fat Embolism Syn (%) 30 25 24 Figure 1. Percentage of hospitalized patients with 20 the fat embolism syndrome (syn) who had isolated or multiple fractures of the femur (other than 17 neck), tibia or fibula, neck of the femur, or pelvis, humerus, ribs, or ulna. 10 0 Femur Other than Tibia or Fibula Femur Neck Pelvis/Humerus/ Neck Ribs/Radius or Ulna Isolated or Multiple Fractures THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES 473
FESの診断 臨床診断 外傷後の多呼吸, 呼吸苦, 気管分泌液増加. 意識の変容, 点状出血の出現はFESを強く示唆する所見. 血液検査; 明らかに有用なのはPLTのみ. PLT低下(<150k)はFES診断に重要な所見となる. Lipuriaは骨折患者の1/2で認められる. 高感度であり,臨床的に使用できるかははっきりしない. 喀痰中の脂質, リパーゼも骨折患者では多く認められるため, 臨床的にはあまり役に立たない. 血液中のFat dropletsも高感度であり, 特異性は低い.Clinical Orthopaedics and Related Research 2004;232:263-70
診断Criteria (1970) Criteriaは古く, 感度, 特異度ともに不明確. 参考程度に. ≥1 major, ≥4 minorで診断 J Bone Joint Surg Br 1970;52:732–37. J Bone Joint Surg Br 1974;56:408-16 Major Minor 頻脈 発熱≥38.5 PaO2<60mmHg 網膜塞栓 肺水腫 Lipuria 低酸素と関係がない意識障害 説明困難なHtの低下 腋窩, 結膜の点状出血 PLT低下 ESR上昇 喀痰中の脂肪滴
100名のFES患者の解析 臨床症状 呼吸器症状は75名で認められ,呼吸苦,多呼吸,湿性ラ音が主. PaO2<50が24/50名, 50-80が17/50名. 胸部XPは52名で評価され, 43/52で両側性びまん性浸潤影. 9/52で正常所見であった. 中枢症状を呈したのは80名. 様々なレベルの意識障害を来す. 50 per cent or more was found THE FAT EMBOLISM in twenty-three, with SYNDROME minimum values of un millimetre in twelve patients. In eighty-seven cases the erythrocyte sedimenta raised, with values of 30 to 50 millimetres in sixteen cases, 51 to 70 millimetres cases, and over 71 millimetres in fifty-four cases. Fat globules larger than 点状出血斑は57名.初期では腋窩の前方,頚部で多く認められる. found circulating the clinical severity in all cases. The amount of the condition. of circulating fat did not appear 頬粘膜,結膜でも認めやすい. 眼底所見は54/63で正常. .‘. CThe Journal of Bone and Joint Surgery 1974;56:408-16 FIG. 2
puted tomography scans of the 4 patients diagnosed with FES and with a nodular pattern at CT exami 4名のNudular Patternを示したCTnodules were small, with ill-deﬁned margins and a centrilobular and subpleural distribution. A, Patient J Comput Assist Tomogr 2006;30:254-7 pattern (arrowheads) and alveolar opacities in the lower lobes. B, Patient 3 has subpleural nodules (arro
Figure 1. Continued Figure 1. Continued Ovid: Pulmonary Fat Embolism Syndrome: CT Findings in Six Patients.Figure 1. Continued Figure 1. Continued On CT scans, multifocal areas of consolidation and ground-glass opacity were seen in all patients. These areas of consolidation and ground-glass opacity ranged from 10 to 40 mm (Fig. 1). In another patient, diffuse consolidation was noted as well as multifocal areas of consolidation and ground-glass opacity, which involved all lobes (Fig. 2). Nodules were seen in all patients. The nodules ranged from 2 to 10 mm and were well defined in three patients and ill defined in three. The nodules were closely associated with the peripheral branch pulmonary Figure 2. Continued artery in three patients (Fig. 1). All three of these characteristics were seen predominantly in the upper lobes in Journal of Computer Assisted Tomography 2000;24:24-29 five patients. In the remaining patient, the abnormal opacities involved all lobes evenly. In four patients, these
FESの治療 基本的には対症療法 早期発見, 血ガスフォロー, 酸素投与が基本. Shockがあれば大量補液. 骨折の早期内固定も重要. 化学的肺損傷を予防する目的での ステロイド大量投与は有効かもしれない.Clinical Orthopaedics and Related Research 2004;232:263-70