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Bone cement implantation syndrome (BCIS)

Bone cement implantation syndrome (BCIS). Department of Anaesthesia, University Hospital of South Manchester Br J Anaesth 2009; 102: 12 – 22. 전공의 3 년차 노지성. Background. BCIS cause of morbidity and mortality in cemented hip arthroplasty Increase in the number of ASA II and III patients

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Bone cement implantation syndrome (BCIS)

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  1. Bone cement implantation syndrome (BCIS) Department of Anaesthesia, University Hospital of South Manchester Br J Anaesth 2009; 102: 12–22 전공의 3년차 노지성

  2. Background • BCIS cause of morbidity and mortality in cemented hip arthroplasty • Increase in the number of ASA II and III patients undergoing a THR in recent years • Between April 2006 and March 2007보고: • length ofstay • 9.8 days (cemented primary THR) vs. 8.6 days(uncemented procedure) • mortality after cemented and uncemented primary THR • 2.3% and 1.6% • 2000~3 National Institute for Health and Clinical Excellence (NICE) guidelines • long-term viability(cemented prosthesis):better results

  3. Search strategy • Medline search for the phrases; • bone cement, bone cement implantation syndrome, arthroplasty, hip replacement, complications, methyl methacrylate (MMA), and monomer Definition • No agreed definition • a number of clinical features: hypoxia, hypotension, cardiac arrhythmias, increased pulmonary vascular resistance (PVR) and cardiac arrest-hip arthroplasty에만 국한된 것은 아님 • Occur at one of the five stages in the surgical procedure;‘pericementation period’

  4. Proposed definition of BCIS • cemented bone surgery. • occurring around the time of cementation, prosthesis insertion, reduction of the joint or, occasionally, limb tourniquet deflation • hypoxia • hypotension • unexpected LOC Proposed severity classification of BCIS • Grade 1: moderate hypoxia (SpO2<94%) or hypotension (fall in SBP > 20%) • Grade 2: severe hypoxia (SpO2<88%) or hypotension (fall in SBP > 40%) or unexpected LOC • Grade 3: cardiovascular collapse requiring CPR.

  5. Incidence • not possible to draw true incidence : under-reported, lack of a standard definition • A study of 48 patients: 1 patient (2%) suffered significant hypotension and 8 patients (17%) developed significant desaturation • A study of 55(cemented long-stem hip arthroplasty): hypotension in 38%, desaturation in 25%. • mortality data • Only three large case during cemented THR : 0.11% • The largest study in 1999 • 23 in 23,077 : intra-operative deaths patients (cemented arthroplasty) • 11 deaths in 11,655 cemented total hip arthroplasties, • 12 during 2,814 cemented hemiarthroplasties • Because of cardio-respiratory problems during cementation

  6. Clinical features • Wide spectrum of severity • in the peri-cementation period • significant, transient reduction in SpO2 ,BP • smaller proportion: profound intra-operative cardiovascular changes, which may proceed to arrhythmias, shock or cardiac arrest • embolization of femoral canal contents to the cerebral circulation post-operative delirium • A case report- BCIS during hemiarthroplasty Intra-operative cardiac arrest후 의식 회복이 안되어 MRI F/U: suggestive of multiple cerebral fat emboli

  7. Etiology and pathophysiology 1 • not fully understood • Proposed several mechanisms • Initial theories: focused on the release into the circulation of MMA cement monomer • More recent research : the role of emboli formed during cementing and prosthesis insertion • histamine release, complement activation, and endogenous cannabinoid-mediated vasodilatation

  8. Etiology and pathophysiology 2 • Monomer-mediated model • BCIS에서 혈역학적 변동은 cementing시 monomer에 의해 일어난다는 이론. • 하지만 이는 monomer의 직접적인 작용이라기 보다는 intramedullary pressure(IMP)결과로 인한 것이며, 이로써 embolization을 일으킨다. • Embolic model • Echocardiography: Embolism발견 • Post-mortem studies: pulmonary embolization • 물리적인 효과와 mediator 방출의 결과 • pulmonary vascular tone을 증가mechanicalembolization • Mechanism of emboli formation • cementation 과 prosthesis insertion 때 IMP 증가, cement의 온도가 높아져 prosthesis 와 bone, trapping air 와 medullary contents 사이의 공간이 확장되어 혈류로 밀려 들어간다. • Cementation은 cement gun 이나손으로 femoral canal을 packing pressures가 생성된다.(Table 3)

  9. Etiology and pathophysiology 2

  10. Etiology and pathophysiology 3 • Transosophageal echocardiography (TOE) • emboli in the heart using TOE and these vary greatly in size and number (Fig. 1) • A study • emboli in 47 out of the 48 patients. • appearance of multiple small emboli as a ‘snow flurry’ • Emboli greater than 10 mm: 1/3에서 발견됨 • most marked during reaming of both the femur and acetabulum, and during insertion of the femoral component and reduction of the hip joint

  11. Fig. 1 (A) Small emboli ( <5 mm) filling less than half of the right atrium. • (B) Medium-sized emboli (5–10 mm, arrowed) and small emboli filling more than half of the right atrium. • (C) Small emboli ( <5 mm) completely filling the right atrium, multiple paradoxical emboli in left atrium. • (D) Large emboli ( >10 mm) in the right atrium with delayed • passage at the tricuspid valve.

  12. Etiology and pathophysiology 4 • Evidence of emboli at autopsy • marrow, fat, bone emboli, and MMA microparticles in the lungs • fat emboli: brain, kidneys, and myocardium • The link between IMPand embolization • embolization 은 IMP와 비례한다. • 상한효과도존재함 • 즉, 이런 현상은 femoral canal 에 존재하고 있는 debris 양이 제한 때문이었다. (Fig. 2).

  13. Fig 2 . Number of fat emboli in the lungs (area of 1200 mm2) and the maximum mean IMP over a 10-s interval. • Reproduced with permission from Waddell and Byrick

  14. Etiology and pathophysiology 5 • The haemodynamic effects of embolization embolize to the lungs, heart or paradoxically to the cerebral and coronary circulations hypoxia & hypotension (because of RV dysfunction) • Mediator release from emboli • damage of endotheliumreflex vasoconstriction or release of endothelial mediators • embolic material may release vasoactive or pro-inflammatory substances increase PVR

  15. Fig 3. Pulmonary vessel with embolus comprising fat, platelets, fibrin & marrow debris. • Reflex vasoconstriction and endothelial production of endothelin 1. • Release of vasoconstriction mediators; platelet derived growth factor (PDGF), serotonin • (5-HT), thromboxane A2 (Tx-A2), platelet activating factor (PAF), adenosine • diphosphate (ADP). • (3) Vasoconstriction attributable to non-cellular components of embolus including thrombin.

  16. Etiology and pathophysiology 6 • Problems with the embolic model • Embolization이 항상 혈역학적 변동과 연관된 것은 아니고, • Embolism의 정도가 hypotension 이나 hypoxemia의정도와 관련성이 부족 • 또한 TOE study에서 보면 embolic event는 보이나, V/Q mismatch는 정상으로 유지된다. • micro-embolism 은 BCIS에서 기여인자 이긴 하나, 아마도 다른 mechanisms도 공존할 것으로 추측 • Histamine release and hypersensitivity • 1972년에 발표된 BCIS의 치명적인 case에서는 Anaphylaxis (Type 1 hypersensitivity)가 복합적으로 관련되었을 가능성이 있었다. • 또한 cementation 을 받는 저혈압 환자에서는 plasma histamine concentration이 증가

  17. Etiology and pathophysiology 7 • Complement activation • cemented hemiarthroplasty에서 C3a와 C5a 수치 증가가 증명 • Multimodal model • clinical features may depend upon the individual’s physiological response • patient’s pre-existing co-morbidities may alter the clinical features of BCIS

  18. Patient risk factors & Surgical factors • old age • poor pre-existing physical reserve • impaired cardiopulmonary function • Osteoporosis, bony metastases • concomitant hip fractures • particularly pathological or intertrochanteric fractures • PFO or ASD emboli and neurological sequelae 증가

  19. Anaesthetic risk reduction • ASA score of three or over • 14% of primary hip arthroplasty • 26% of revision procedure full investigation of co-morbidity and pre-optimization이필요. • Depending on individual patient and the type of prosthesis • Avoiding i.v. depletion-reduce the extent of the haemodynamic changes in BCIS • haemodynamic monitoring • CVP: volume optimization, • pulmonary artery catheter, TEE in high risk patients.

  20. Surgical risk reduction • several modifications in the surgical & anaesthetic technique • Medullary lavage • good hemostasis before cement insertion • minimizing the length of the prosthesis • venting the medulla • reduces the risk of an air embolus • But, risk of femoral fracture • Retrograde cement insertion • mixed cement in a partial vacuum

  21. Management • 마취의사와 수술의사와의 Communication 중요 • the early indication of BCIS • A fall in ETCO2 • Esophageal Doppler measurements • Regional A. : dyspnea and altered sensorium • Recommendations • 경험과 case reports ,basic physiological principle 의해 판단 • a cemented prosthesis should be avoided in patients at high risk of BCIS • BCIS 가 의심될 경우, • oxygen concentration 100% 유지 • be treated as RV failure • pure alpha agonist ora mixed alpha and beta receptor agonist • Hemodynamic instability • Sympathetic a1 agonists (first-line agent) • if there is insufficient pre-load : aggressive resuscitation with i.v. fluids • central venous catheter-CVP monitoring

  22. 감사합니다

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