Perioperative support of a patient with fat embolism syndrome with extracorporeal membraneoxygenation

Fat embolism syndrome (FES) is a serious complication of trauma that can result in multiorgan failure, including the acute respiratory distress syndrome. Occasionally, the severity of respiratory failure associated with FES warrants support with venovenous extracorporeal membrane oxygenation (VV-ECMO), a therapy with widespread use but inconclusive evidence. Early definitive fracture fixation is the mainstay of preventing further fat embolism and ongoing organ dysfunction, but poses significant risks to the maintenance of the extracorporeal circuit. We describe a rare case of a patient who required VV-ECMO for respiratory support prior to fracture fixation. The risks of intraoperative fat embolisation causing sudden circuit failure were managed by having a spare circuit available outside the operating room with readiness for an emergency circuit change. Postoperative fat deposition in the oxygenator was managed by a circuit change. Our case is the first to describe preoperative initiation of VV-ECMO for FES and highlights why this therapy should not delay definitive fracture fixation and how it can be safely managed in this setting.