Hip fractures pose a medical, societal, and economic burden with only one third gaining the functional recovery and one third succumbing to mortality [
7]. Furthermore, those undergoing hemireplacement arthroplasty has incidence of syndrome as 20% [
2] with cemented prosthesis showing 0.11% mortality risk according to registry reports occurring mostly at the time of cementation [
1]. Mortality figures were even higher as 0.5% in Norway study [
8]. The mortality risk for grade III BCIS as in our case was as high as 88% (Table
2) [
2]. Most of the figures were based upon observational study with most data extracted from arterial blood pressure measurement, oxygen saturation data charted on anesthetic records [
3]. Our observation was also based upon Invasive blood pressure measurement, oxygen saturation data, and clinical observation of mental status and taking into account the proposed classification by Donaldson [
1]. Additionally, comorbid condition mainly cardiac, respiratory, malignancy, osteoporotic changes increase the risk of the syndrome complex [
1,
2]. Literature review hypothesize the multifactorial model of pathogenesis according to postmortem finding of patient succumbing to intraoperative mortality for the syndrome complex which shows massive pulmonary fat embolism as a major culprit along with mast cell activation [
9‐
11]. Anaphylaxis with release of mediators [
12,
13] to monomer of bone cement, embolus [
10] has also been proposed giving similar pictures as embolic model. There are also reports of patients requiring intensive care [
14] and succumbing to death postoperatively [
9,
15] particularly in patients who were unstable in intraoperative periods. It is difficult to come to conclusion of etiology in our case as we didn’t have the luxury of transesophageal echocardiography as well as the family members didn’t consent for postmortem examination but probably a multifactorial model would explain the phenomenon. Adverse clinical events with coma and death has been reported in patient having femoral metastasis who underwent cemented arthroplasty [
16].
Table 2
Proposed grading [
1] adverse events [
21] and estimated 30-day mortality [
2]
Grade I | Moderate hypoxia (SPO2 < 94%) or Hypotension [fall in systolic blood pressure (SBP) > 20%] | ~ 20% | 9.3% |
Grade II | Severe hypoxia (SpO2 < 88%) or Hypotension (fall in SBP > 40%) or Unexpected loss of consciousness. | ~ 3% | 35% |
Grade III | Cardiovascular collapse requiring Cardiopulmonary Resuscitation | ~ 1% | 88% |
Risk reduction can only be achieved with vigilant monitoring from both the surgeon and the anesthesiologist (Table
3) [
3,
17]. Cemented arthroplasty although increases the mortality rate at first day, however has better mortality indices thereafter and improves pain and refractures rate compared to uncemented arthroplasty [
18]. Careful reaming of the femoral canal with use of cement gun is recommended for frailer patient [
19] which is less likely to happen in our set up. Better hemodynamic monitoring, early recognition and aggressive resuscitation and changes in surgical technique are recommended for prevention of catastrophic outcome [
15]. Insertion of arterial pressure measurement, use of end tidal carbon dioxide particularly in vulnerable group gives more liberty to address the hemodynamic stability early [
3]. If the patients develop the syndrome, cardiovascular collapse should be treated as Right ventricular failure with use of alpha-1 agonist and maintaining preload [
1,
20].
Table 3
Three-stage process to reduce the incidence of problems in patients undergoing cemented hemiarthroplasty for proximal femoral fracture [
17]
1. Identification of patients at high risk of cardiorespiratory compromise: |
a. Increasing age; |
b. Significant cardiopulmonary disease; |
c. Diuretics; |
d. Male sex. |
2. Preparation of team(s) and identification of roles in case of severe reaction: |
a. Pre-operative multidisciplinary discussion when appropriate; |
b. Pre-list briefing and World Health Organization Safe Surgery checklist ‘time-out’. |
3. Specific intra-operative roles: |
a. Surgeon: |
• Inform the anesthetist that you are about to insert cement; |
• Wash and dry the femoral canal; |
• Apply cement retrogradely using the cement gun with a suction catheter and intramedullary plug in the femoral shaft; |
• Avoid excessive pressurisation. |
b. Anesthetist: |
• Ensure adequate resuscitation pre- and intra-operatively; |
• Confirm to surgeon that you are aware that he/she is about to prepare/apply cement; |
• Maintain vigilance for signs of cardiorespiratory compromise. Use either an arterial line or non-invasive automated blood pressure monitoring set on the ‘stat’ mode during/shortly after application of cement; |
• Early warning of cardiovascular collapse may be heralded by a drop in systolic pressure. During general anesthetic, a sudden drop in end-tidal pCO2 may indicate right heart failure and/or catastrophic reduction in cardiac output; |
• Aim for a systolic blood pressure within 20% of pre-induction value; |
• Prepare vasopressors in case of cardiovascular collapse. |
Patient with femoral metastasis undergoing cemented arthroplasty are at high risk of developing high grade BCIS. Careful identification of risk factor with aggressive perioperative monitoring and changes in surgical technique can reduce the risk of bone cement implantation syndrome.