Bone Cement Implantation Syndrome

Bone cement implantation syndrome (BCIS) is hypoxia, hypotension and arrhythmia, or collapse, occurring at cementation, prosthesis insertion, joint reduction or tourniquet release in cemented arthroplasty. It is most often seen in hip hemiarthroplasty for fracture.

Epidemiology. Mild BCIS affects up to 20% to 30% of cemented hemiarthroplasties, with severe forms in 2% to 5% and death in about 0.1% to 0.6%. It carries significant mortality (up to 20% in grade 3).

Severity. Grade 1: moderate hypoxia (saturation under 94%) or fall in systolic blood pressure of 20% to 39%. Grade 2: severe hypoxia (saturation under 88%) or fall in systolic pressure of 40% or more, or unexpected loss of consciousness. Grade 3: cardiovascular collapse requiring cardiopulmonary resuscitation.

Risk factors. Age over 75 years, ASA 3 to 4, cardiopulmonary disease, pulmonary hypertension, osteoporosis, pathological fracture, long stem or press fit prostheses, hip fracture, diuretics, warfarin use, and absence of venting.

Pathophysiology.

Pressurisation of the femoral canal forces marrow fat, air, bone debris and cement monomer into the circulation, causing pulmonary microemboli, raised pulmonary vascular resistance, right heart strain, hypoxia, and complement mediated inflammation. Monomer causes vasodilation.

Within minutes of cementation: fall in saturation, fall in end tidal carbon dioxide, hypotension, arrhythmia, bradycardia, raised pulmonary artery pressure, agitation or loss of consciousness (awake patients under spinal anaesthesia) and cardiac arrest.

Red flags.

• Saturation under 88%.
• Systolic blood pressure fall of 40% or more.
• Loss of consciousness.
• Cardiac arrest.

Clinical, with timing against cementation or joint reduction. Echocardiography shows right ventricular strain. Exclude other causes of collapse.

Differential diagnosis.

• Pulmonary embolism.
• Fat embolism.
• Anaphylaxis (cement monomer, antibiotic).
• Myocardial infarction.
• Haemorrhage.
• Tension pneumothorax.

Warn the surgeon, stop further cementation, give 100% oxygen, and maintain circulation.

• Phenylephrine: 50 to 100 microgram IV every 1 to 2 minutes; maximum 200 microgram/min as infusion; monitor blood pressure; reduce in bradycardia.
• Noradrenaline: 0.05 to 0.5 microgram/kg/min; maximum 1 microgram/kg/min; monitor arterial pressure.
• Adrenaline: 10 to 100 microgram IV, then 0.02 to 0.2 microgram/kg/min; for arrest 1 mg IV every 3 to 5 minutes; monitor ECG and arterial pressure.
• Fluid bolus 250 to 500 mL crystalloid in hypovolaemia, but avoid overload.

Use inhaled nitric oxide for pulmonary hypertension where available. Start chest compressions for arrest.

Prevention. Identify high risk patients and consider uncemented prostheses, reduce cement pressure, use cement gun with retrograde filling, wash and dry the canal with high pressure lavage, vent the femoral canal, avoid hypovolaemia, raise inspired oxygen to 100% before cementation, maintain blood pressure with vasopressors and have arterial line monitoring (high risk patients).

Monitoring. Arterial pressure, saturation, end tidal carbon dioxide and ECG until 30 minutes after cementation.

Referral and escalation. Critical care after severe events. Orthopaedic and anaesthetic multidisciplinary review of cemented implants.

Special groups. Older adults with hip fracture and heart disease have the highest risk.