What is the management and treatment of bone cement syndrome?

Management and Treatment of Bone Cement Implantation Syndrome

Bone cement implantation syndrome requires a three-pronged approach: aggressive prevention through meticulous surgical technique and hemodynamic optimization, immediate recognition through vigilant monitoring at four critical moments, and rapid resuscitation with 100% oxygen, fluid boluses, and vasopressors when cardiovascular collapse occurs. 1

Understanding BCIS Severity

BCIS presents on a graded spectrum that determines management intensity 1:

• Grade 1: Oxygen saturation <94% or >20% fall in systolic blood pressure (occurs in ~20% of cases) 2
• Grade 2: Oxygen saturation <88% or >40% fall in systolic blood pressure or loss of consciousness (occurs in ~3% of cases) 2
• Grade 3: Requires cardiopulmonary resuscitation (occurs in ~1% of cases, but carries 3.5-fold increased 30-day mortality) 2, 3

The incidence varies by procedure: hip hemiarthroplasty (31%), TKA (28%), THA (24%), with overall occurrence in 26% of cemented arthroplasty procedures 3.

Prevention Strategies: The Foundation of Management

Preoperative Risk Stratification and Optimization

Identify high-risk patients who require enhanced monitoring and preventive measures 1, 3:

• Age >75 years (OR 1.57) 3
• ASA Class III or IV (OR 1.58) 3
• Renal impairment (OR 3.32, the strongest predictor) 3
• Male sex, significant cardiopulmonary disease, and diuretic use 1

Ensure adequate hydration before induction and throughout surgery to avoid intravascular volume depletion, which is essential in preventing BCIS 1, 4.

Team Communication Protocol

The surgeon must verbally announce intent to instrument the femoral canal, and the anesthesiologist must verbally confirm awareness 2, 1. This should occur during both the pre-list briefing and WHO Safe Surgery checklist "time-out" 1.

Surgical Technique Modifications

The surgeon must execute these steps precisely 2, 1:

• Thoroughly wash and dry the femoral canal using pressurized lavage system to remove fat and marrow contents 2, 1
• Place distal suction catheter on top of intramedullary plug 2, 1
• Insert cement from gun in retrograde fashion on top of the plug 2, 1
• Pull suction catheter out immediately when blocked with cement 2, 1
• Avoid excessive manual pressurization or pressurization devices in high-risk patients 2, 1
• Minimize prosthesis length and insertion force 1

Anesthetic Preparation and Monitoring

Maintain systolic blood pressure within 20% of pre-induction values using vasopressors and/or fluids 2, 1. Specific measures include:

• Use invasive arterial line monitoring in high-risk patients, or set non-invasive automated blood pressure monitoring to 'stat' mode during/shortly after cement application 2, 1
• Have vasopressors immediately available (metaraminol/epinephrine) drawn up and ready 2, 1
• Increase inspired oxygen concentration to 100% at time of cementation 1

Intraoperative Management: The Four Critical Moments

Maintain heightened vigilance during four high-risk moments when BCIS typically occurs 1, 5:

1. Femoral head removal 1
2. Femoral canal preparation 1
3. Cement insertion and prosthesis placement 5
4. Joint reduction 5

Monitoring for Early Warning Signs

During general anesthesia, watch for 2:

• Sudden drop in end-tidal CO₂ (indicates right heart failure and/or catastrophic reduction in cardiac output) 2
• Drop in systolic pressure (early warning of cardiovascular collapse) 2
• Hypoxia, arrhythmias 4, 5

Acute Management When BCIS Occurs

When cardiovascular compromise develops, implement aggressive resuscitation immediately 1, 4:

Immediate Interventions

• Deliver 100% oxygen immediately 1
• Fluid resuscitation guided by CVP measurement 1
• Vasopressor/inotropic support (use prepared vasopressors without delay) 1, 4
• Execute predefined institutional protocols with all theatre staff performing assigned roles 1

Resuscitation Protocol

If cardiac arrest occurs, high-quality cardiopulmonary resuscitation is essential 4. The case report literature demonstrates successful resuscitation is possible even in patients with multiple comorbidities when immediate CPR is initiated 4.

Note on antihistamine prophylaxis: Despite theoretical rationale based on histamine release, a prospective randomized trial found that H1 and H2-receptor-blocking agents do NOT prevent BCIS and showed slight (non-significant) disadvantage 6. Do not rely on antihistamines for prevention.

Postoperative Management

Immediate Postoperative Period

• Administer supplemental oxygen for at least 24 hours 1
• Monitor in recovery unit or HDU/ICU as clinically indicated 1
• Patients remain at high risk for complications in the early postoperative phase 1

Ward-Level Care

• Maintain nurse:patient ratio of 1:4 1
• Regular vital sign monitoring including oxygen saturation 1

Critical Clinical Context

Despite BCIS risk, cemented prostheses for hip fracture surgery provide pain-free mobility, reduce re-operation risk, and are associated with lower 30-day mortality compared to uncemented prostheses 1. This evidence supports continued use of cemented fixation with appropriate preventive measures rather than abandoning the technique.

The key pitfall is failure to recognize that severe BCIS (Grades 2-3) carries a 3.5-fold increased risk of death within 30 days 3. Therefore, prevention through the systematic approach outlined above is far superior to reactive management.