Bone Cement Implantation Syndrome ini a 73 years old Female undergoing Hemiarthroplasty

Surgery : A Case Report

Sidiq. Muhammad A.1, Laksono. Buyung H.2

1.
Anesthesiology resident, 2.Anesthesiology Consultant

Brawijaya University, Saiful Anwar General Hospital, Malang.

Abstract

A 73 years old Female was admitted to our hospital with the diagnosis of fracture of neck of left
femur and posted for hemiarthroplasty. The patient was managed with Combined Spinal Epidural
Anesthesia using 20mg of 0,5% Bupivacaine heavy was used for spinal anesthesia. Incremental dose
of 0,75% ropivacaine was later to prolong the duration of sensory and motor block. Five minutes
after bone cement implantation, saturation dropped to 80-83% and there was refractory
hypotension. The patient was managed with loading of colloids, ephedrine, Positive pressure
ventilation and administration of Dopamine infusion. The patient was admitted to the ICU after
surgery and was pronounced dead 2 days later.

Keywords : Bone Cement implantation syndrome, neuraxial anesthesia, geriatric.

Introduction

Bone Cement Implantation Syndrome (BCIS) is a rare and fatal complication of bone cementation
used in orthopaedic procedures. The main clinical features include hypotension, hypoxia, altered
mental status and even cardiac arrest. Early diagnosis and treatment is an important factor in
determining the outcome of BCIS.1 Management of BCIS is mainly supportive including maintaining
patent airway, Oxygenation, Fluid rescucitation and use of vasopressors according to Basic Life
Support (BLS) and Advanced Cardiovascular Life Support (ACLS) guidelines. 2

Case History

A 73 years old Female was admitted to our hospital with a history of fall. The patient complained of
pain and tenderness of the right hip and difficulty in walking. Radiographic examination revealed a
fracture of neck of left femur. The patient was planned to undergo hemiarthoplasty of the left hip.

Anesthetic Management

The patient was assessed as physical status ASA 3 with comorbid as follows : geriatry, hipoalbumin
2,81, HT on terapi (captopril, amlodipin, TD 120/70), Azotemia .The patient was managed with
Combined Spinal Epidural Anesthesia using 20mg of 0,5% Bupivacaine heavy was used for spinal
anesthesia. Incremental dose of 0,75% ropivacaine was later to prolong the duration of sensory and
motor block. Hemodynamic was stable, with mild hypotension treated successfully using ephedrine

Five minutes after bone cement implantation, saturation dropped to 80-83% and there was
refractory hypotension, the patient was still conscious. The patient was given a loading of colloids,
and ephedrine was administered. Positive pressure ventilation was given and saturation rose to 95%.
5mcg/kgBB/min of Dopamine then was administered using syringe pump. Stable Blood pressure was
achieved with MAP around 65-70. The operation continued and after surgery the patient was
admitted to the ICU.

Twelve hours post operative, the patient’s condition declines, saturation was dropped, and severe
hypotension occurs. Cardiac arrest occurred, the patient was rescuscitated with CPR, fluids and
vasopressors and the patient was intubated. After 2 cycles of CPR, ROSC achieved. The patient then
managed with ventilator support and NE 1mcg/kgbb/mnt, Dobutamin 5mcg/kgbb/mnt, Dopamin
14mcg/kgbb/mnt, Epinefrin 1mcg/kgbb/mnt. Two days after, the patient further deteriorates and
was pronounced dead.

Discussion

Bone Cement Implantation syndrome (BCIS) is a rare and fatal complication of cemented
orthopaedic surgeries. BCIS is characterized by hypoxia, hypotension or both and/or unexpected loss
of consciousness occurring around the time of cementation in a patient undergoing cemented bone
surgery.1,2 Other complications of BCIS include pulmonary hypertension,pulmonary edema,
bronchoconstriction, cardiac dysarrythmia, cardiac arrest, hypothermia and thrombocytopenia. 3
Some of the proposed causes of BCIS include toxic effects of systemically absorbed methyl
methacrylate, high intramedullary pressures due to pressurizing effect of bone cement or reaming,
and fat embolism.4,5 Constant monitoring and supportive management is crucial in determining the
outcome of patient with BCIS. Management includes maintaining patent airway, Oxygenation, Fluid
rescucitation and use of vasopressors /inotropic according to Basic Life Support (BLS) and Advanced
Cardiovascular Life Support (ACLS) guidelines . Geriatric patients may have co existing disease which
can increase the likelihood of BCIS. Patient risk stratification, Intraoperative vigilance, Good
communication with the oprator,and prompt resuscitation are the key in the management of BCIS. 6,7

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