Intra-operative crises · Core21 / 21
Bone cement implantation syndrome with aortic stenosis86-year-old woman, 52 kg, frail; displaced intracapsular hip fracture
Bone cement implantation syndrome: RV failure at cementing in a frail patient
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Know this first
- BCIS: hypotension, hypoxia, arrhythmia, raised PVR, RV failure or arrest at cementing.
- Risk: increasing age, diuretics, cardiopulmonary disease, male sex, metastases, long-stem prosthesis.
- Keep systolic within 20% of baseline; invasive BP for higher-risk patients.
- Aortic stenosis: preload and afterload maintained, sinus rhythm, no tachycardia.
- Treatment is supportive: oxygen, fluid, vasopressors, adrenaline for the RV.
The patient
86-year-old woman, 52 kg, frail; displaced intracapsular hip fracture.
Moderate aortic stenosis on a recent echo; sinus rhythm.
Drugs: furosemide.
Cemented hemiarthroplasty on the next trauma list.
Vitals: BP 138/70, HR 82, SpO2 94% on air, RR 18.
The examiner asks
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Consider
What are your concerns?
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- An 86-year-old frail woman with moderate aortic stenosis, for cemented hemiarthroplasty. Patient
- At 86 and frail, I check her cognition and baseline; delirium risk is high.
- Her BCIS risks: age, diuretic use, and significant heart disease. Disease
- Her valve needs preload and afterload kept up, sinus rhythm, and no tachycardia.
- Cementing pressurises the canal; marrow emboli raise PVR and can fail her RV. Surgery
- For high-risk patients an uncemented stem is an option; I raise it with the surgeon.
Prepare
How do you prepare for cementing?
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- Agreed call: surgeon announces cementing, and I confirm I've heard. Surgery
- Surgeon washes and dries the canal, vents it, guns the cement and avoids excess pressure.
- Arterial line before induction, given her valve and BCIS risk. Disease
- Well filled before induction; her furosemide leaves her dry.
- Systolic held within 20% of her baseline with fluid and vasopressor.
- Noradrenaline and adrenaline ready before cementing; phenylephrine 50–100 mcg for induction dips. Crisis
- Her ceiling of care agreed with her and her family before theatre. After surgery
Crisis
As the cement goes in, SpO2 falls to 85%, BP to 68/40, HR 112. What do you do?
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- BCIS at cementing: surgeon told, help called. Crisis
- 100% oxygen and ventilation supported.
- Noradrenaline or adrenaline first, noradrenaline from 0.05–0.1 mcg/kg/min; phenylephrine only if the RV looks well.
- Not responding: adrenaline to support her failing right ventricle.
- Fluid bolus, judged against how distended her RV looks.
- Tachycardia raises her heart's oxygen demand; restoring pressure is the fix. Disease
Crisis
BP becomes unrecordable; the arterial trace is flat and the ECG shows sinus rhythm at 50. What now?
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- Adult arrest algorithm: PEA, non-shockable, from BCIS and RV failure. Crisis
- CPR now, turning her supine; adrenaline 1 mg IV without delay.
- Then adrenaline 1 mg every 3–5 minutes.
- Reversible causes in her: pulmonary embolism of marrow and cement, bleeding, hypoxia.
- Echo if available, to see her RV and look for tamponade or an empty heart.
- After ROSC: ICU, and her family told. After surgery
Fatal mistakes
- No warning or communication before cementing.
- Accepting hypotension in aortic stenosis.
- Inadequate support for a failing right ventricle.
- Fluid loading alone into a dilated RV.
Checked against: Anaesthesia for hip fracture repair (2020) · Miller 10e · Barash 9e
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