Cementing Aims and rationale Best Practice Avoid the use of uncemented implants where Where a hemi-arthroplasty is indicated, consider a cemented prosthesis in all patients. possible When it is not clear whether to use a cemented or non-cemented implant, this decision Uncemented implants lead to increased post-operative pain, should be made jointly by a consultant orthopaedic surgeon and consultant anaesthetist poor mobility and a higher rate of revision surgery than cemented prostheses. However cemented implants have a higher risk of BCIS and increased day-of-surgery mortality Both pre-morbid mobility prior to fracture and risk factors for BCIS should be Consider the risk of bone cement implantation taken into account syndrome (BCIS) in all patients where a cemented Risk factors include: prosthesis may be used BCIS is usually seen as an abrupt change in physiology at the time of femoral instrumentation or cementing BCIS stage 1 (moderate hypoxaemia <94%) BCIS stage 2 (sats <88%, fall in BP by 40%, sudden LOC) BCIS stage 3 (cardiovascular collapse requiring CPR) BCIS in hip fracture patients confers an increase in 30d mortality from 5% to 9%, 35% and 88% for BCIS 1, 2 & 3 COPD and ASA III/IV status both increase the risk of BCIS two-fold Use low viscosity cement in patients at risk of BCIS Reducing the risk of BCIS Consider canal lavage prior to cementing Risk of BCIS appears to be proportional to intramedullary canal pressure at the time of cementing. Low viscosity cement has a Aggressive maintenance of normotension, especially at the time of cementing, lower risk of BCIS than high viscosity. Canal lavage prior to may reduce paradoxical embolisation cementing may also reduce risk Consider invasive monitoring and GDFT in patients at risk of BCIS Signs of BCIS include systemic hypotension, hypoxaemia, Maintain vigilance during instrumentation of the canal and cementing, and bradycardia, arrhythmias, pulmonary hypertension and maintain good communication between surgeon and anaesthetist cardiac arrest In patients where you suspect BCIS has occurred, consider post-operative admission to critical care
Cementing Aims and rationale Avoid the use of uncemented implants where possible Uncemented implants lead to increased post-operative pain, poor mobility and a higher rate of revision surgery than cemented prostheses. However cemented implants have a higher risk of BCIS and increased day-of-surgery mortality Consider the risk of bone cement implantation syndrome (BCIS) in all patients where a cemented prosthesis may be used BCIS is usually seen as an abrupt change in physiology at the time of femoral instrumentation or cementing BCIS stage 1 (moderate hypoxaemia <94%) BCIS stage 2 (sats <88%, fall in BP by 40%, sudden LOC) BCIS stage 3 (cardiovascular collapse requiring CPR) BCIS in hip fracture patients confers an increase in 30d mortality from 5% to 9%, 35% and 88% for BCIS 1, 2 & 3 Reducing the risk of BCIS Risk of BCIS appears to be proportional to intramedullary canal pressure at the time of cementing. Low viscosity cement has a lower risk of BCIS than high viscosity. Canal lavage prior to cementing may also reduce risk Signs of BCIS include systemic hypotension, hypoxaemia, bradycardia, arrhythmias, pulmonary hypertension and cardiac arrest Best Practice Where a hemi-arthroplasty is indicated, consider a cemented prosthesis in all patients. When it is not clear whether to use a cemented or non-cemented implant, this decision should be made jointly by a consultant orthopaedic surgeon and consultant anaesthetist Both pre-morbid mobility prior to fracture and risk factors for BCIS should be taken into account Risk factors include: COPD and ASA III/IV status both increase the risk of BCIS two-fold Use low viscosity cement in patients at risk of BCIS Consider canal lavage prior to cementing Aggressive maintenance of normotension, especially at the time of cementing, may reduce paradoxical embolisation Consider invasive monitoring and GDFT in patients at risk of BCIS Maintain vigilance during instrumentation of the canal and cementing, and maintain good communication between surgeon and anaesthetist In patients where you suspect BCIS has occurred, consider post-operative admission to critical care
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