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Bone Cement Implantation Syndrome During Cemented Shoulder Arthroplasty
Session: MP-07c
Fri, April 20, 1:15-2:45 pm
Plymouth (Shubert Complex), 6th floor

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Patient History:
• 76 year-old woman with left shoulder osteoarthritis presented for a left total shoulder replacement
• Medical history:
    o Cardiac amyloid with left ventricular ejection fraction of 20%
    o Moderate mitral and aortic regurgitation
    o Bradycardia requiring a pacemaker  (PPM)
    o Ventricular tachycardia requiring an implantable cardio-defibrillator (ICD)
Perioperative Course:
• Surgery was performed under regional (single shot interscalene block) and general anesthesia in the beach chair position
• An arterial line and defibrillator pads were placed preoperatively
• PPM programmed to VOO at 60 beats per minute
• The operative course was uneventful until seconds after insertion of methylmethacrylate (MMA) bone cement:
     o Blood pressure to a nadir 50/25, MAP 36
     o SpO2 from 98% to 91%
     o ETCO2 from 40 to 34
Immediate Management:
• Surgeon alerted
• FiO2 increased 100%
• Hypotension was addressed by reversing the beach chair position, administration of fluid, and phenylephrine boluses (total 320mcg)
• SpO2 and blood pressure normalized within minutes and she remained stable for the duration of the surgery
• The underlying cause of this episode was suspected to be bone cement implantation syndrome (BCIS)
Bone Cement Implantation Syndrome:
• BCIS is a rare and potentially fatal complication occurring in patients undergoing cemented arthroplasty with MMA.  It is primarily associated with cemented arthroplasty of the hip but has been observed with cemented knee and spine procedures.  There are rare case reports of BCIS during shoulder arthroplasty
• Characterized by hypotension, bradycardia, arrhythmias, hypoxia, and increased pulmonary vascular resistance (PVR).  Awake patients may experience dyspnea and altered sensorium
• Occurs during cementation, prosthesis insertion, joint reduction, or tourniquet deflation
Inciting Event:  Cement Insertion
• Cement undergoes an exothermic reaction and expands in the space between bone and prosthesis causing intramedullary hypertension
• Subsequent embolization of marrow, fat, cement particles air, bone particles and aggregates of platelets and fibrin.
• MMA can cause cardiopulmonary changes secondary to vasodilation 
Etiology and pathophysiology: 
Two models have been described: Embolic and Monomer-mediated
• The presence of embolic material in circulation may cause obstruction to forward flow, histamine release and endogenous cannabinoid mediated vasodilation
• Cement can cause an increase in PVR; pulmonary hypertension (pHTN) contributes to right ventricular (RV) failure and hypoxia
• The thin walled RV dilates, shifts the intraventricular septum to the left, decreases left ventricular (LV) filling, causing decreased cardiac output (CO ) and hypotension
• Hypotension reduces coronary perfusion pressures (CPP); reduced right coronary flow and increased  right ventricular end-diastolic pressure (RVEDP) contributes to ischemia
• MMA monomer may cause vasodilation
BCIS Risk Factors:
Patient Risk Factors:
• Increasing age
• Cardiopulmonary disease
    o Impaired cardiopulmonary function, pHTN, and RV dysfunction are susceptible to effects of increased PVR
• Osteoporosis, bony metastases
• Poor pre-exiting physical reserve
Surgical Risk Factors:
• Pathological fractures
    o Abnormal vascular channels
• Long stem prosthesis
• Undisturbed medullary canal
    o More potentially embolic material
Intraoperative Roles:
Anesthesiology Team:
• Vigilant hemodynamic monitoring during cement insertion
    o Arterial line or non-invasive blood pressure cuff on “stat” mode (if indicated)
• Optimize hemodynamics, oxygenation, and volume status
    o 100% FiO2
    o Blood pressure within 20% baseline
    o Vasopressors available or given prophylactically
Surgical Team:
• Inform anesthesia team prior to cement application
• Wash and dry femoral canal
• Avoid excessive pressurization
• Apply cement retrograde with intramedullary vent
Management:  Early and Aggressive Resuscitation 
• Cardiovascular collapse should be treated in line with RV failure
• Main priority is to maintain coronary perfusion pressure and cardiac output:
    o Vasopressors (phenylephrine) facilitate peripheral vasoconstriction and increased myocardial perfusion
    o Inotropes (dobutamine, epinephrine) support ventricular contractility
    o Pulmonary vasodilators reduce PVR and RV afterload
    o IV fluids maintain RV preload
    o Pacing (as in this case) prevents bradycardia and facilitates cardiac output
• Consider additional hemodynamic monitoring:
    o TEE may help assess RV function
    o PA catheter may help monitor CO and guide resuscitation
    o Central access facilitates vasopressor and inotrope administration
• BCIS can occur in cemented arthroplasty of the shoulder.  Patients with significant cardiac dysfunction can recover from BCIS, provided that it is rapidly recognized and treated
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