Massive intraoperative pulmonary embolism: it may not be as bad as it looks...

An elderly patient suffered a cardiac arrest while undergoing repair of a pathological femoral fracture. Intraoperative transoesophageal echocardiography demonstrated massive pulmonary embolism. Pulmonary embolectomy was considered inappropriate in view of her underlying terminal disease, so a decision was made to withdraw all further supportive measures. Despite this, the patient's haemodynamics improved spontaneously. The embolic material was presumed to be bone marrow fat. Fat may traverse the pulmonary circulation; hence the clinical consequences (and management implications) of massive intraoperative pulmonary embolism may vary, depending on the composition of the embolic material. As there are no reliable means of determining the composition of embolic material intraoperatively, the clinical suspicion of fat embolism poses a management dilemma. Should these cases be managed surgically or conservatively?