Dr Alyani HSNZ. case illustration introduction definition incidence clinical features aetiology and...
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Transcript of Dr Alyani HSNZ. case illustration introduction definition incidence clinical features aetiology and...
case illustration introduction definition incidence clinical features aetiology and pathophysiology risk factors risk reduction and management
51 years old malay male involved with motor vehicle accident. He complaint of pain over right hip and unable to ambulate after that.
He is a chronic smoker and did not have any medical illness before.
Right hip radiograph showed comminuted fracture neck of right femur extending to lesser tubercle.
He was planned for bipolar hemiarthroplasty and posted for operation on day 3 of admission
Spinal anaesthesia was performed at spinal level of L3,L4
One and half hour of surgery,during reaming of medulary cavity, the surgeon noted hairline fracture extending to midshaft of the femur hence planned to attach the implant with bone cement
One minute after cement implantation, there was severe bradycardia, hypotension and desaturation until 78% and he went into cardiac arrest.
The surgery was stop, he was repositioned and CPR was commenced. He was intubated with ETT size 8.0mm.
After 2cycles of chest compression his conscious level improving and bradycardia and hypotension also improved.
The surgery then proceed uneventfuly
A 59-year-old Indian lady had allegedly slipped and fallen in a sitting position in the bathroom of her house.
She was admitted to hospital and was subsequently diagnosed to have a closed fracture of the neck of her left femur.
She underwent total hip replacement surgery under combined spinal epidural anaesthesia.
During the operation, upon completion of bone cementing, her heart rate suddenly dropped from 100 to 55 per minute, oxygen saturation fell to 76% and she became unresponsive.
Intravenous adrenaline and atropine were immediately given, however, her blood pressure and heart rate continued to fall
The patient was immediately sedated and intubated.
After completion of the surgery, she was transferred to the intensive care unit (ICU).
However despite full inotropic support, she did not respond and passed away approximately twelve hours post procedure
An autopsy examination was subsequently performed
Bone cement was introduced in 1970 Bone cement is a surgical material used in joint art
hroplasty surgery, filling of a bone defect, use in orthopeadic tumour surgery etc
contain 'pearls' that has pre polymerized PMMA (polymethyl metacrylate) in a powder form + liquid monomer of methyl metacrylate (MMA) = mixed with addition of catalyst that initiate polymerization of monomer --> paste.
BCIS is firstly reported after 10years of introduction of bone cement
Under reported Usually described with hip arthroplasty, however it can occur in any procedure that use cement May occur at any stage of bone surgery:femoral reamingacetabular or femoral cement implantationinsertion of prosthesisjoint reductionlimb tourniquet deflation
No agreed definition
Confluent of clinical features that includes:
HypoxiaHypotensioncardiac arrythmiasincreased pulmonary vascular resistence (PVR)cardiac arrest
Grade Characteristic
1Moderate hypoxia (spo2 <94%)
Or hypotension (SBP fall >20%)
2
Severe hypoxia (spO2 < 88%)
Or hypotension (SBP fall > 40%)
Or unexpected loss of consciousness
3 Cardiovascular collapse requiring CPR
Study Incidence of hypotension Incidence of mortality
Lafont et al 1997
n=48 (cemented THR)
2% SBP>30%
17% desaturation >5%
Coventry et al 1974
n=1684 (cemented THR) 0.06%
Ereth et al. (1992)
n=15 211(cemented THR)
n=6684 (uncemented THR)
0.12%
0%
Parvizi et al. (1999)
n=11655 (cemented THR)
n=11011(uncemented
THR)
0.09%
0%
Spectrum of severity
Increased PVRincreased pulmonary arterial pressureRV EF reduced (further distended RV pushing septum to LV, further reducing filling)reduce SVreduce COreduced MAP
transient but may persists up to 48hours
significant transient reduced in O2 saturation and
SBP
profound CVS changes
(arythmia/shock/arrest)
Features suggestive of cerebral vessel embolisation such as delirium or focal neurological deficit
emboli from the canal that escape pulm circulation or thru a potent foramen ovale
evidence by demonstrated cerebral emboli by doppler USG in 40-60% of patient undergoing joint arthroplasty
The pathophysiology and pathogenesis of BCIS is not fully understood
Suggested model: monomer mediated model embolic model histamine release and hypersensitivity multimodal model
MMA monomer in circulation causing vasodilatation but not supported as plasma MMA level after cem
ented arthroplasty < required level to cause CVS effect
Hence, it is suggested that BCIS is due to increase intramedullary pressure during cementation causing the cement to become embol
Evidence: emboli detected in RA, RV, pulmonary artery by echo, pulmonary embolization in post mortem study
Emboli content : fat, marrow, cement particles, air, bone particles, aggregates of fibrin and platelets
Mechanism :Increase intramedullary pressure as a result of: cement packing in the medullary canal using finger packing or cement guncement undergoes exothermic reaction and expands in space between prosthesis and boneprosthesis insertion with the cement inside
trapped air, medullary content under pressure forced into circulation.
Presence of the emboli will cause:
Mechanical stimulation and damage of endothelium result in reflex vasoconctriction or release of endothe
lial mediators
Embolic material may release vasoactive or proinflammatory substance that directly increased PVR, eg: thrombin / tissue thromboplasti
n
Release of chemical media
tors systemically can cause reduction in SVR such as
PG 1alfa, tissue thromboplastin
Case 2 : autopsy examination Lungs : showed bone marrow elements in the blood vessels, composed of fat admixed with haemopoietic precursor cells. Fat was also observed in the pulmonary sinusoids.
Heart : showed marrow elements adherent to the endocardium
Fat, marrow elements and amorphous material were also seen within the blood vessels of the liver and kidneys.
Kidney : showed features of acute tubular necrosis.
The cause of death was disseminated microembolization as a consequence of hybrid total hip replacement surgery
Pancreas : showed acute inflammatory cell
infiltrates, patchy areas of
haemorrhage and necrosis and
surrounding fat necrosis
Fat cells in blood vessels
significant increased in plasma histamine concentration in hypotensive patient undergoing cementation (type 1 hypersensitivity)
unclear increase in c3a and c5a level (complement a
ctivation) --> potent vasoconcstrictors and bronchoconcstriction
PATIENT FACTOR SURGICAL FACTOR
Old age poor preexisting physical r
eserve preexisting pulmonary hyp
ertension Osteoporosis* bony metastasis* concomittant hip fracture**Abnormal or increased vas
cular channels in marrow
previously uninstrumented femoral canal (higher risk than a revision surgery)
use of long stem femoral component
anaesthetic volatile agent may be assoc with greater haemodynamic changes for the same embolic load
avoidance of nitrous oxide to avoid exacerbating air embolism
avoiding intravascular volume depletion high level intraoperative vital signs monitori
ng in high risk patient such as IABP,central venous catheter
Do a medullary lavage Good homeostasis before cement
insertion Minimizing the length of prosthesis Using non cemented prosthesis Venting the medullary canal Mixed the cement in partial vacuum
rather than at atmospheric pressure
Communication between surgeon and anaesthetist before the operation is performed especially in high risk patient
Fall in ET C02 is the first indicator of BCIS In awake patient, early sign may include
dyspnoea and altered sensorium Management mainly empirical and according
to the presentation If BCIS is suspected, inspired oxygen should
be increased to 100% To treat CVS collapse as RV failure –
aggressive recussitation with IV fluid is recommended
Inotropic support if needed Administration of sympathetic alfa 1 agonist
Bone cement implantation syndrome, A.J. Donaldson, HE Thomson, NL Harper, NW Kenny, Manchester UK, British Journal of Anaesthesia, 2009
BCIS – A Case Report, Anish KA, Suranjith Sorake, S.Padmanabha, Mangalore India, IOSR Journal of Dental and Medical Sciences, December 2013
Case report, Bone Cement Implantation Syndrome, Razuin R, Effat O, Shahidan MN, Shama DV, MFM Miswan, Faculty of medicine, UiTM, Hosp Sungai Buloh, Malaysian Journal of Pathology, 2013
Bone Cement and Implication for anaesthesia, Gautam Khanna, Jan Cemovsky, Oxford Journal , Feb 2012