What is the management of cement effect hypotension after arthroplasty?

Management of Cement Effect Hypotension After Arthroplasty

The management of bone cement implantation syndrome (BCIS) hypotension requires immediate vasopressor administration, fluid resuscitation, and supportive care to maintain systolic blood pressure within 20% of pre-induction values. 1

Understanding Bone Cement Implantation Syndrome

Bone cement implantation syndrome (BCIS) is characterized by hypotension, hypoxia, and potential cardiovascular collapse that occurs during cemented arthroplasty procedures. The severity is classified into three grades:

• Grade 1: Arterial saturation <94% or >20% fall in systolic blood pressure (~20% incidence) 1
• Grade 2: Arterial saturation <88% or hypotension >40% fall in systolic blood pressure or loss of consciousness (~3% incidence) 1
• Grade 3: Cardiovascular collapse requiring cardiopulmonary resuscitation (~1% incidence) 1

Risk Factors for BCIS

Certain patient factors increase the risk of severe cardiovascular events during cemented arthroplasty:

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

Immediate Management of Cement Effect Hypotension

Cardiovascular Support

• Administer vasopressors promptly - metaraminol or adrenaline (epinephrine) should be readily available and given in case of cardiovascular collapse 1
• Provide fluid resuscitation to ensure adequate intravascular volume 1
• Target systolic blood pressure within 20% of pre-induction values 1

Respiratory Support

• Increase FiO2 to maintain adequate oxygenation 1
• Monitor arterial oxygen saturation continuously 1
• Watch for sudden drops in end-tidal CO2 during general anesthesia, which may indicate right heart failure or catastrophic reduction in cardiac output 1

Monitoring

• Use invasive blood pressure monitoring (arterial line) in high-risk patients 1
• Set non-invasive blood pressure monitoring to "stat" mode during and shortly after cement application 1
• Maintain vigilance for early signs of cardiovascular compromise 1

Prevention Strategies for Future Procedures

Anesthetic Considerations

• Consider regional or neuraxial anesthesia in addition to general anesthesia, as this may reduce BCIS incidence (general anesthesia alone has 4.5-5.8 times greater odds of BCIS development compared to combined techniques) 2
• Ensure adequate hydration before induction and during anesthesia 1

Surgical Techniques

• Use thorough femoral canal preparation with pressurized lavage system to clean endosteal bone of fat and marrow contents 1
• Employ distal suction catheter with intramedullary plug 1
• Apply cement in retrograde fashion using a cement gun 1
• Avoid vigorous cement pressurization in high-risk patients 1
• Ensure complete bleeding control on the acetabular side, as this reduces the tendency for blood pressure to decrease 3

Team Communication

• Establish clear communication between surgeon and anesthetist before cement application 1
• Surgeon should verbally announce intent to prepare femoral canal and apply cement 1
• Anesthetist should confirm awareness of cement application 1

Long-term Considerations

Research indicates that cement use in hemiarthroplasty is associated with increased 1-year mortality (HR 1.9,95% CI 1.3-2.7) 4, highlighting the importance of proper management and prevention of BCIS. However, cemented prostheses also provide benefits including increased pain-free mobility and reduced reoperation rates 1.

Common Pitfalls to Avoid

• Failure to anticipate BCIS - Always be prepared for cardiovascular collapse in cemented arthroplasty 1
• Delayed recognition - Early warning signs include drops in systolic pressure 1
• Inadequate preparation - Have vasopressors drawn up and ready before cement application 1
• Poor communication - Ensure the surgical team maintains clear communication about cement application timing 1