DP62: "WHEN CEMENT STOPS THE HEART: GRADE 3 BONE CEMENT IMPLANTATION SYNDROME DURING DISTAL FEMORAL REPLACEMENT"
Adam Henderson, Medical Student; Rupashi Mukhia, MBBS, MD; Eric Deloso, DO, MS; Paul A Rizk, MD
Mayo Clinic
Introduction: Bone cement implantation syndrome (BCIS) is a serious complication of cemented arthroplasty using methyl methacrylate which causes moderate to severe hypoxia and hypotension. BCIS results from embolization of cement, fat, or air into the pulmonary circulation, along with histamine release triggered by bone cement. While BCIS occurs in approximately 26% of cemented procedures, severe BCIS (Grades 2-3) is less common but carries grave prognosis, with Grade 3 BCIS associated with 88% early mortality and 16-fold increase overall mortality.
Case Presentation: We present a 66-year-old male with paraplegia from T8 spinal cord injury, end-stage renal disease (ESRD) on hemodialysis, preoperative anemia (hemoglobin 5.9 g/dL) scheduled for a cemented total knee arthroplasty and distal femoral replacement due to traumatic left distal femur fracture. Prior cardiac workup included myocardial perfusion study less than 6 month prior with a moderately severe fixed defect, however, the patient was asymptomatic when exercising with hand bike. Preoperatively, we confirmed hemodialysis was performed one day prior and transfused 2 units packed red blood cells. General anesthesia was selected given his spinal cord injury, and induction was uneventful. Immediately following cement placement, hemodynamic collapse occurred with profound hypotension refractory to vasopressors, end-tidal CO2 declined, oxygen saturation dropped <40%, and pulseless electrical activity (PEA) arrest is ensued. This was consistent with Grade 3 BCIS. Three rounds of CPR were performed, and a return of spontaneous circulation was achieved. Intraoperative TEE revealed an EF of 10-15%. The procedure was aborted, cement removed, and the patient transferred to the ICU. He was successfully extubated 4 hours after arrival at the ICU, and vasopressors were weaned off in less than 24 hours. Two days postoperative there was no neurologic sequelae; the patient’s primary complaint was rib fracture–related pain.
Discussion: This case highlights BCIS management in a high-risk patient. His ESRD, ASA IV status, anemia, and coronary perfusion defect represent established BCIS risk factors. Other known risk factors are age >75 years, ASA >III, and COPD. Specifically, ESRD confers an odds ratio of 3.32 for severe BCIS.
During the case, the surgical team clearly communicated when placing the bone cement, which helped with the prompt diagnosis and treatment of grade 3 BCIS. This helped minimize postoperative complications and allowed for rapid recovery in the ICU.
Conclusion: As the U.S. population ages and patients present with increasingly complex comorbidities, awareness of BCIS risk factors along with multidisciplinary communication can allow for timely diagnosis and management of BCIS. Consideration should be given to neuraxial or regional anesthesia when feasible as these techniques may reduce BCIS incidence. Additionally, bone cement usage could be increasing as there is increasing evidence to support its use in aging population to prevent postoperative periprosthetic fractures.