Over the last two decades, hip surgery with methylmethacrylic cement has become a popular and suecessful procedure. Improvements in the techniques of surgery and anesthesia have led to increased numbers of operations in the elderly. However, cardiovascular collapse is an occasional but well documented complication of the use of acrylic bone cement during hip surgery. Although the etiology has not yet been completely resolved, fat or air emboli and hypersensitivity to the methylmethacrylate monomer have been implicated. We have now documented two cases of fatal cardiovascular collapse during orthopedic surgery, presumably resulting from intraoperative fat embolism.journal articl

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HANAGATA, Kazuyuki

IWASHITA, Hironobu

KASHIMOTO, Satoshi

KUMAZAWA, Teruo

NAKAMURA, Toshihiro

NONAKA, Akihiko

English

University of Yamanashi Academic Repository

Yamanashi Med. J. 9(2), 65･h-･68, l994Fatal Cardiovascular Collapse during Insertion of Bone                and a Prosthesis: Two Case ReportsCementToshihiro NAKAMuRA, Satoshi KAsmMoTo, H[ironobu lwAsmTA, Akihiko NoNAKA,               Kazuyuki HANAGATA, and Teruo KuMAzAwA             DePartment ofAnesthesiologly, Yamanashi Medical UniversdyAbstract: Over the last two decades, hip surgery wlth methylmethacrylic cement has become apopular and successful procedure. Improvements in the techniques of surgery and anesthesiahave led to increased numbers ofoperationsin the elderly. However, cardiovascular collapse is anoccasional but well documented complication of the use of acrylic bone cement during hipsurgeryi-4). Although the etiology has not yet been completely resolved, fat5) or air emboli6) andhypersensitivity to the methylmethacrylate moRomer7)-iO) have been implicated. We have nowdecumented two cases of fatal cardiovascular collapse during orthopedic surgery, presurnablyresulting from intraoperative fat embolism.Key words: Bone cement, Cardiovascular collapse, Fat embolismCASE REPORTS  Case 1: AR 86-year-old woman sustained afracture of the left femoral neck. The patientwas approximately l45 cm tal} and weighed 40kg. There was a history of severe dementia andleft hemiplegia due to m"ltiple cerebral infarc-tioR. Her family reported no history of anginapectoris, pulmonary disorder, or thrombeerR-bolic disease. However, preoperative arterialblood gas analysis showed an arterial Pa02 of63 mmHg, an arterial PaC02 of 29 mmHg,and pH of 7.5l5. Although total bilirubiR wasiRcreased to 2.46 mgldl, other laboratory datawere within normal limi£s. Four days afteradmission to hospital she was scheduled forprosthetic replacement of £he femoral head.  As the patient was excitable and exhibi£edsevere dementia, we selected general anesthe-sia. Afterthe application of routine monitorsReceivedAcceptedTamaho,February 22, 1994April 26, 1994Nakakoma, Yamanashi 409-38, Japan(blood pressure cuff, electrocardiogram, pulseoximeter), general anesthesia was induced with･thiamylal and vecronium given intravenously,'and maintaiRed with sevoflurane and nitrousoxide in oxygen. [Irhe patieRt was carefullyturned a"d placed in the right decubitusposition. Oxygen saturation (Sp02) was main-tained at 98%, blood pressure ffuctuated be-tweeB 150186 and 96154 mmHg, and pulse was58-68 beatslmiR until the placement of theacrylic cerfient. Following the maRual place-ment of the acrylic cement in the femoralshaft, the heart rate decreased from 58 to 38beatslmiR, and blood pressure and Sp02 couldBot be obtaiRed. Although pure oxygen sup-plementation was given immediately, aRdephedrine 20 mg and atropine } mg weregiven intravenously, bleod pressure remainedt}Bobtainable. Isoproterenol, epiRephriBe, andnorepinephrine were also administered. How- ever, the patieitt did not respond to these drugs. The surgeons were urged to close the operative site as rapidly as possible, and cardio-pulmonary resuscitation (CPR) was beguR af-ter the patient was placed in the supineposition. Arterial blood gas analysis revealedPa02 15.7 mmHg, PaC02 41.8 mmHg, pH7.234. Attemp£s at resuscitation were abaR-doRed 7e min after the beginning of CPR.IRtraoperative blood loss was estimated at 90mL.  Case 2: An 88-year-old woman sustained asubcapital fracture of the right femoral neck.The patient was 140 cm tall and weighed 35kg. There was a history of hypertension.Preopera£ive blood pressure fiuctuated be-£ween 160190 and I40170 mmHg, aRd pulsewas 60-75 beatslrr}in. She had no history ofangina pectoris, pulmonary disorder, orthromboembolic disease. However, Preopera-tive arterial blood gas analysis showed anarteri'al Pa02 of 52 mmHg, an arterial PaC02of 30 rnmHg and a pH of 7.515. She hadanemia (hemoglobin 8.9 gldl), but this was notcorrected preoperatively with a blood transfu-sion. Other laboratory data were within nor-mal limits. Fifteen days after admission tohospital she was scheduled for prosthetic re-placement of the femoral head.  After application of the routine moRitors,the patient was carefully tumed and placed inthe left decubitus position. A 23-gauge spinalneedle was inserted into the subarachnoidspace at the lumbar 218 interspace and aseksory level to Th-8 was obtained with 8.2 mlof e.5% bupivacaine. Prior to spinal anesthesia,blood pressure was 145175 mmHg, heart ra£ewas 80 beatslmin, aRd Sp02 was 92 %. After thepatient was placed in the left decubitus posi-tion, Sp02 decreased from 92% to 84% andblood pressure was Il4164 mmHg. Althoughthe patient did not complain of dyspnea,oxygen supplemen£ation was given immediate-ly, using a face mask. Care was takeit to replaceblood loss with packed red cell altd ba}ancedelectrolyte solutioR. The patient's coRditionwas satisfactory uRti} the begiRning of medul-lary reaming. Approximately 5 minutes afterthe acrylic cement was placed in the femeralNakamura,  et al.shaft with a cement gun, £he patient's heartrate decreased from 75 to 40 beatslmiR. Bloodpressure could not be ob£ained and she be-came severely disoriented. Ephedrine IO mgwas given intravenously. Bradycardia per-sisted, aRd blood pressure remained unobtain-able. The surgeons were urged to close theoperative site as rapidly as possible. Thepatient was intubated and manual veRtilatioltofthe lungs with pure oxygen was performed.Epinephrine O.5'mg was given intravenouslyand epinephrine I mg was given by intra-tracheal tube. However, the electrocardiogramstill indicated bradycardia (30 bea{slmin),which did not respond to epinephrine. Bloodpressure was also gtnobtainable. Approximate-ly 5 minutes after the bradycardia had begun,the patieB£ was placed in the supine position,and extemal cardiac massage was commenced.Arterial aRd central vein ca£heters were in-serted into the left femoral artery and vein,respectively, and blood gas analysis revealedPa02 75 mmHg, PaC02 39 mmHg, pH 7.16,aRd serum potassium 4.2 mEqlL. Althoughepinephrine 1 mg was given into the centralvein catheter, the bradycardia became severer.At£ernpts at resuscitation were abandoned 60min after the beginning of CPR. Intra-operative bloed loss was estimated at 150 mL.               DIscussloN  CemeRt toxicity was originally thought to becaused by myocardial depressieB aRd vasodila-tion, brought about by absorption of the liquidacrylic monori}er2'7'i}). Certainly, the substaRcecan cause these effects when iajected intoanimalsi2), but £he blood levels measuredduriRg operation in hgmans are far too low tocause a sys£emic reactioni3).  It is xxow widely accepted that most complica-tions that occur during hip surgeries arecatised by fat embolism}4'i5). The methyl-methacrylic cement exacerbates embolism bysealing the femoral shaft, and this creates avery high intramedullary pressure (pressuresCardiovascular Collapse during a Prosthesis 67greater thaR 600 mmHg have beenrecorded)i6). This increased pressure forcesmore fat emboli into the circulation.  CliRically unsuspected hypoxemia is com--monly seen after fracturesi7) and it has beenpostulated that this may be the result ef fatembolusi8}. In healthy youRg males, it wasreported tha£ prolonged recumbency (10 daysin bed) may have caused aR increase in thealveolar-arterial oxygen partial pressuredillferences]9). These factors may explaiR thecirculatory collapse in the second patient.  However, there is aRother possible explana-tioit for the circulatory collapse. Open venoussinuses in the femoral canal, as well as thepatient being in the dec"bitus position (withhip above hear£), favor air entrapment duringthis operation. Various methods have beenutilized to reduce the }ikelihood of venous airembolism duriRg hip surgery. Harvey andSmith}O) reperted a decrease from 16% to O%when the femoral shaft was insufflated withCOg. Evans et al.20) reduced the incidence from100% to 33% when the femoral cement wasinserted with a cement gun, rather than byrr}anual ipstillatioR. Heinrich et al.2i) redi.icedthe incideRce from 92% to 30% with theplacemcrnt of a venting hole in the femeralshaft. In our second patient, we did Rot ventthe medullary cavity ef the femur with acatheter orwith drillholes in the femoral shaft,and the femoral cement was inserted with acement gun, so that the volume of air withinthe femoral medullary cavity was limited.Therefore, the possibility of air embolism as amain cause of cardiac collapse iB this patieittseems to be low.  Barron22) and Sherman et al.23) suggestedthat the most important surgical considera-tions ifl hip replacement were removal of theprodi-}cts of medullary reaming by lavage oraspiration, and venting of the shaft to lowerintrameduliary pressure. In our two patientssurgeoRs took great care wi£h medullary ream-ing and did not insert the acrylic cement iBtothe femeral medullary cavity until it was firmenot}gh to be corwentioRally handled, so as todiminish absorption of free acrylic monomersinto the general circulation. Mereover, iR thesecond patient, the femoral cement was in-serted with a cement gun. However, we wereunable to prevent cardiovascular collapse inthese two patiRets.  In summary, we had the experience of fatalcardiovascular collapse during erthopedicsurgery, presumably resulting from intra-operative fat embolism. We believe that theoythopedic surgeon and the anesthetist shouldalways be aware of this petentially life-threatening cemplication when using press-fitfemoral components.              REFERENCES 1) Powell JN, McGrath PJ, Lahiri SK, et    al.. Cardiac arrest associated with bone ce-    meRt Br Med J 1970; 3: 326. 2) PkillipsH,ColePV,LettinAWF.Cardiovascu-    lar effects ofimplanted acrylic bone cement. Br    Med J l970; 3: 460-461. 3) Dandy QJ. Fat embolism following prosthetic    replacement of the femoral head. Iajury 1971;    3: 85-88. 4) CharnleyJ. Risks oftotal hip replacement. Br    Med J 1975; 4: 101. 5) Modig J, Busch C, Olerud S, et al. Arterial    hypotension and hypoxaemia during total hip    replacement: The importance of thromboplas-    tic products, fat embolism and acrylic monom-    er. Acta Anaesth Scand 1975; 19: 28-43. 6) Hyland J, Robins RHC. Cardiac arrest and    bone cement Br Med J 1970; 4: l76-177. 7) PeeblesDI,EllisRH,StrideSDK,etal.Cardio-    vascular effects of methylmethacrylate cement.    Br Med J 1972; 1: 349. 8) Schuh FT, Schuh SM, Viguera MG, et aL    Circulate bone cement Anesthesiology 1973;    39: 455-457. 9) Park WY, Balingit P, Kenmore PI, et al.    Changes in arterial oxygen tension during total    hip replacement. Anesthesiology 1973; 39:    642-644.10) HarveyPB,SmithJA.Preventionofairemboli    in hip surgery. Femoral shaft insufflation with    carbon dioxide. Anaesthesia l982; 37: 714-    717.Il) Homsy CA, Tullos HS, Anderson MS, et al.68 T. Nakamura,    Some physiological aspects of prosthesis stabi-    lization with acrylic polymer. Clin Orthop    1972; 83: 317-328.12) Douglas JP, Richard HE, Stride SDK, et al.    Cardiovascular effects of methylmethacrylate    cement. Br Med J l972; 1: 349-351.13) Cohen CA, Smith TC. The in£raoperative    hazard ofacrylic bone cement: report ofa case.    Anesthesiology 1971; 35: 547-549.K) OrsiniEC,ByricRJ,MulleRJBN,etal.Cardio-    pulmonary function and pulmonary microem-    boli during arthreplasty using cemented or    noncemented compenents. J Bone Joint Surg    1987･ 69A: 822.        ,15) Byrick RJ, MullenJBM, KayJC, et al. Preven-    tion of fat ai]d marrow microembolism during    cemented arthroplasty. Trans Orthop 1988;    13: 550.I6) BarronDW.IRtramedullarypressurepattems.    Clin Orthop l979; 145: 188-186.I7) Tachakra SS, Sevitt S: H[ypoxaemia after frac-    ture. J Bone Joint Surg 1975; 57: 197.et al.18) Ross ARJ. The fat embolism syndrome: with    special reference to the importance of hypoxia    in the syndrorr}e. Ann R Coll Surg l970; 46:    159.19) Cardus D. 02 alveolar-arterial tension differ-    ence after IO days recumbercy in man.J Appl    Physiol l967 7: 934.20) Evaiis RD, Palazzo rV{GA, Ackers JWL. Air    embolism during total hip replacement: com-    parison of two surgical techniques. Br J    Anaesth I989; 62: 243-247.2I) HeiBrich H, Kremer P, Winter H, et al. Trans-    esophageal two-dimeBsional eckocardiography    during total hip replacement. Anaesthesist    1985; 34: 118-123.22) BarronDW.Intramedullarypressurepatterns.    Clin Orthop 1979; 145: 183-186.23) ShermanRM,ByrickRJ,KayJC,etal.Theroie    of lavage in preventing hemodynamic and    blood gas charges duriBg cemented arthro-    plasty. J BoneJoint Surg 1983; 65A: 500-506.

<Case Report> Fatal Cardiovascular Collapse during Insertion of Bone Cement and a Prosthesis: Two Case Reports

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<Case Report> Fatal Cardiovascular Collapse during Insertion of Bone Cement and a Prosthesis: Two Case Reports

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