- Bone cement implantation syndrome
Link:bja.oxfordjournals.org/content/102/1/12.full.pdf
- Characterised by hypoxia, hypotension, or both +/or unexpected LOC around the time of cementation, prosthesis insertion, reduction of the joint or tourniquet deflation
- Clinical signs
- Hypoxia
- Hypotension
- Cardiac arrhythmias
- Cardiac arrest
- Increased PVR
- Can occur at one of several stages
- Femoral reaming
- Femoral cement implantation
- Insertion of prosthesis
- Joint reduction
- Aetiology
- Likely multimodal, poorly understood
- May be due to monomethyl acrylate (MMA) microemboli or high intramedullary pressures (fat, bone, air, platelets, fibrin emboli)
- Causes histamine release, complement activation, and cannabinoid-mediated vasodilatation
- Grades
- 1
- Moderate hypoxia (SpO₂ <94%), decrease in SBP of >20%
- 2
- Severe hypoxia (SpO₂ <88%), decrease in SBP of >40% or unexpected LOC
- 3
- CV collapse requiring resuscitation
- Treatment
- 100% O₂
- Vasopressors
- CPR in event of arrest
- IV fluids
- Risk factors
- Old age
- Poor pre-existing health (ASA III/IV)
- Long femoral stems
- Bony metastasis
- Pathological fractures
- Pre-existing PAH
- Un-instrumented femoral canal
- Intertrochanteric fracture
- Manual packing of the cavity vs. cement gun - no clear benefits
- Non-venting of the femoral shaft
- Risks femoral fracture with drilling for vent
- Mixing cement in atmosphere rather than vacuum
- Higher incidence of death in atmosphere group