|Year : 2015 | Volume
| Issue : 4 | Page : 569-571
Bone cement implantation syndrome: A dreaded complication during arthroplasty
Jaspreet Kaur Nagpal, Pramod Madhav Velankar, Sandeep Choudhary, Venkatesh Nutangi
Department of Anesthesiology, Dr. D.Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||14-Jul-2015|
Pramod Madhav Velankar
908, Deccan Gymkhana, Off Fergusson College Road, Pune - 411 004, Maharashtra
Source of Support: None, Conflict of Interest: None
Bone cement implantation syndrome is a known cause of intraoperative morbidity and mortality in patients undergoing cemented arthroplasty. It is a rare but potentially fatal complication. A case of elderly female patient is reported who developed this complication during hemi arthroplasty of right hip. Within a few minutes of cementation, she developed severe hemodynamic derangement and shock with hypoxemia. Aggressive and early resuscitative measures led to a favorable outcome. Risk factors, etiopathogenesis and management of this condition are discussed in brief.
Keywords: Bone cement implantation syndrome, cemented hip arthroplasty, complication, etiopathogenesis, management
|How to cite this article:|
Nagpal JK, Velankar PM, Choudhary S, Nutangi V. Bone cement implantation syndrome: A dreaded complication during arthroplasty. Med J DY Patil Univ 2015;8:569-71
|How to cite this URL:|
Nagpal JK, Velankar PM, Choudhary S, Nutangi V. Bone cement implantation syndrome: A dreaded complication during arthroplasty. Med J DY Patil Univ [serial online] 2015 [cited 2020 Feb 26];8:569-71. Available from: http://www.mjdrdypu.org/text.asp?2015/8/4/569/160801
| Introduction|| |
Bone cement implantation syndrome (BCIS)is a rare and a potentially fatal intraoperative complication occurring in patients undergoing cemented bone surgery.  It is an acute catastrophic intraoperative event and is characterized by hypoxia, hypotension, cardiac arrhythmias, increased pulmonary vascular resistance (PVR), unexpected loss of consciousness, cardiac arrest or a combination of these features leading to death in 0.6-1% of patients.  It occurs at one of the five stages in the surgical procedure; femoral reaming, acetabular or femoral cement implantation, insertion of the prosthesis or joint reduction. Occasionally it also occurs around the time of limb tourniquet deflation following total knee replacement surgery. We report a rare case of BCIS in an elderly patient which occurred during hemiarthroplasty under spinal anesthesia (SA).
| Case Report|| |
The 75-year-old female patient was admitted with inter trochanteric fracture right femur following accidental fall in the bathroom on the previous day. She was posted for hemiarthroplasty right hip. Her preanesthetic evaluation was unremarkable except that she was detected to have hypertension. All relevant investigations including electrocardiogram (ECG) and two-dimensional echocardiography were normal except hemoglobin of 9.8 g%. Her hypertension was controlled preoperatively with amlodipine 5 mg and she was then accepted for surgery under SA in American Society of Anesthesiologists (ASA) grade II. On the operation table intravenous (iv) infusion of ringer lactate was started and she was given SA with 3 ml 0.5% hyperbaric bupivacaine. On achieving adequate sensory and motor block surgery was conducted in left lateral position. Intraoperatively she was monitored with pulse oximetry (pulse rate [PR] and oxygen saturation (SpO 2 )], noninvasive blood pressure (BP) and ECG. She was given oxygen supplement with a Venturi mask. During the surgery, her hemodynamic parameters were stable with PR varying between 68/min and 84/min systolic BP 110-130 mmHg, diastolic BP 72-90 mmHg and SpO 2 100%.
She was given injection hydrocortisone 100 mg iv prior to cement implantation. Liquid methyl methacrylate (MMA) 20 g was injected into the medullary canal using cement gun and long stem femoral prosthesis was inserted. After approximately 4-5 min of cementation the patient became pulseless, BP and SpO 2 were not recordable and she was unresponsive to verbal communication. ECG showed slow heart rate and irregular QRS complexes. So immediately surgery was stopped, and the rate of iv infusion was increased, injection Atropine 0.6 mg was administered iv and repeated 2 min later. The patient was turned supine, intubated and ventilated manually using 100% oxygen. Epinephrine 1 mg diluted in 10 ml normal saline was administered iv and hydrocortisone 100 mg was repeated iv. Epinephrine was repeated in the same dose thrice at 2 min interval and external cardiac compressions were also given. Within 15-20 min pulse in major arteries became palpable but BP remained low at 80-90/35-40 mmHg and hence iv infusion of norepinephrine was started and the drip rate was carefully adjusted to maintain her BP near normal. With these resuscitative measures, the patient showed clinical improvement with her PR around 110-130/min, BP 100-120/70-85 mmHg and SpO 2 91-93%. Subsequently, surgery was hurriedly completed. The patient was then shifted to Intensive Care Unit and managed on ventilator support with FiO 2 1 (100% oxygen) and other supportive measures. Postoperatively, her ECG was normal, other vital parameters were stable and urine output was adequate. Arterial blood gas analysis done at 2 hourly interval showed metabolic acidosis despite good oxygenation and ventilation. Sodium bicarbonate was administered iv 20 meq/h and as per requirement to correct metabolic acidosis. She regained consciousness after about 6 h.Norepinephrine infusion was gradually tapered off over next 6 h. She was weaned off the ventilator over next 12 h. Subsequent postoperative course was uneventful.
| Discussion|| |
We have reported a rare and fulminant intraoperative complication of cemented hemi arthroplasty right hip in an elderly female patient operated under SA. The common indications for total hip replacement or hemi arthroplasty are disabling arthritis, fracture femur as a primary procedure or following failed internal fixation. Cardiovascular collapse associated with cement embolization is a known complication of this procedure although fatality is rare. , Majority of these patients undergoing this surgery are >65-year-old with female/male ratio 2:1 and there has been an increase in the number of ASA grade II/III patients undergoing hip joint surgery in recent years. Our patient was an elderly female who was detected to have hypertension on admission and was, therefore, accepted for surgery under SA in ASA grade II after thorough evaluation. It is known that geriatric patients, patients with impaired cardio-pulmonary function, osteoporosis and preexisting pulmonary hypertension are at a higher risk of developing BCIS.  Our patient was a likely candidate to have these risk factors because of her age, history of the trivial nature of injury and preexisting hypertension.
A combination of various processes are involved in the development of BCIS. Release of MMA cement monomer into circulation causing sudden severe systemic vasodilation and cardiovascular collapse was considered to be the cause of this catastrophic event.  Recently this hypothesis has been ruled out because the concentration of the MMA released into circulation is much less than that required to cause cardiopulmonary effects. 
During arthroplasty, high intramedullary pressure develops (>300 mmHg) during cementation and prosthesis insertion.  Expansion of this cement in the space between the prosthesis and bone as a result of exothermic reaction traps air and medullary contents (fat, marrow, cement particles, air, bone particles, aggregates of platelets and fibrin) in this space under pressure which are forced into circulation as emboli.  The embolic load causes life-threatening systemic hypotension, mechanical obstruction of pulmonary circulation, increase in PVR and pulmonary hypertension, increased central venous pressure (CVP), pulmonary edema and bronchospasm resulting inhypoxemia. ,,
Certain precautions need to be observed in elderly patients posted for hip arthroplasty. These patients must be subjected to thorough preanesthetic evaluation including investigations and preoptimization of co-morbid conditions. Anesthetic technique must be tailored to the individual patient. Use of volatile anesthetics is associated with greater hemodynamic changes for the same embolic load than high dose fentanyl-diazepam anesthesia which is, therefore,, preferred for GA.  High concentration of oxygen must be given throughout. Intraoperatively high level of hemodynamic monitoring is required especially in high-risk patients such as CVP and invasive arterial BP monitoring, use of pulmonary artery catheter and trans-esophageal echocardiography. Et CO 2 monitoring is also essential for surgery under GA as a sudden drop in EtCO 2 is the earliest indicator of BCIS. 
In the event of the occurrence of this complication, the patient should be treated aggressively. Management is essentially supportive, that is, administration of 100% oxygen, control of airway, invasive hemodynamic monitoring, aggressive volume therapy if there is insufficient preload and use of vasopressors (alpha-1 agonists) to raise systemic BP.  We used iv bolus of epinephrine followed by norepinephrine by continuous iv infusion to maintain arterial BP.
We used SA in this case and deliberately did not administer anyiv sedation for fear of cardiorespiratory depression in the elderly patient and also to enable us to detect this complication promptly in a conscious patient as dyspnea and altered sensorium are the early signs of BCIS.
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