What are the preoperative preparations and considerations for a patient undergoing a cemented total hip replacement (THR) for a right neck of femur (NOF) fracture?

Preoperative Preparations for Right NOF Cemented Total Hip Replacement

Careful preoperative preparation and intraoperative management are essential to minimize the risk of bone cement implantation syndrome (BCIS), which can cause significant cardiovascular compromise during cemented hip arthroplasty for femoral neck fractures. 1

Understanding Bone Cement Implantation Syndrome (BCIS)

BCIS is a potentially life-threatening complication that can occur during cemented hip procedures, particularly in frail patients. The syndrome manifests as:

• Grade 1 (occurs in ~20% of cases): Arterial oxygen saturation <94% or >20% fall in systolic blood pressure
• Grade 2 (occurs in ~3% of cases): Arterial oxygen saturation <88% or hypotension >40% fall in systolic blood pressure or loss of consciousness
• Grade 3 (occurs in ~1% of cases): Cardiopulmonary resuscitation required 1

Risk Factors for BCIS

Be aware of patient factors associated with increased risk of severe cardiovascular events:

• Increasing age
• Male sex
• Significant cardiopulmonary disease
• Use of diuretic medication 1

Preoperative Preparations

Medical Optimization

• Ensure adequate hydration before surgery
• Optimize management of cardiopulmonary conditions
• Consider invasive blood pressure monitoring for high-risk patients
• Prepare vasopressors (e.g., metaraminol/adrenaline) in case of cardiovascular collapse 1

Multidisciplinary Discussion

• For high-risk patients, facilitate discussion between surgeons, anesthetists, and orthogeriatricians to minimize perioperative risks
• Plan for the procedure to be performed on a planned trauma list by appropriately experienced surgeons and anesthetists 1

Team Communication

• Identify potential for adverse events during pre-list briefing
• Discuss risk factors during the WHO Safe Surgery checklist "time-out" immediately before surgery
• Ensure all team members understand their roles in case of a severe reaction or cardiopulmonary arrest 1

Intraoperative Management

Anesthetic Considerations

• Maintain vigilance for signs of cardiorespiratory compromise
• Use either arterial line or non-invasive automated blood pressure monitoring set on 'stat' mode during/shortly after cement application
• Monitor for sudden drop in systolic pressure or end-tidal pCO2 (during general anesthetic), which may indicate right heart failure and/or catastrophic reduction in cardiac output
• Aim to maintain systolic blood pressure within 20% of pre-induction values throughout surgery 1

Surgical Technique

• The surgeon must verbally inform the anesthetist before preparing to insert cement
• Thoroughly wash and dry the femoral canal
• Use a pressurized lavage system to clean endosteal bone of fat and marrow contents
• Apply cement in retrograde fashion using cement gun with suction catheter and intramedullary plug
• Avoid vigorous pressurization of cement in high-risk patients 1

Communication During Critical Moments

• Surgeon must ask the anesthetist to confirm awareness of femoral canal preparation
• Anesthetist must confirm to surgeon awareness of preparation for cement and prosthesis insertion
• Maintain clear communication throughout the procedure, especially during high-risk moments 1

Potential Complications and Management

Despite cemented prostheses having better outcomes in terms of pain-free mobility, reduced risk of reoperation, and lower 30-day mortality compared to uncemented prostheses 1, be prepared for:

• Cardiovascular collapse during femoral canal preparation, cement insertion, or hip reduction
• Have vasopressors readily available
• Be prepared to initiate resuscitation protocols if needed

Key Pitfalls to Avoid

1. Failure to identify high-risk patients preoperatively
2. Poor communication between surgeon and anesthetist during critical phases
3. Inadequate preparation for potential cardiovascular collapse
4. Excessive cement pressurization in high-risk patients
5. Insufficient monitoring during cement application

By following these guidelines, the surgical team can minimize the risk of BCIS and other complications during cemented total hip replacement for right neck of femur fractures, improving patient outcomes and reducing mortality.