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Post by katevaughn on Jun 1, 2019 10:39:37 GMT -5
This month’s journal club is presented by Belinda Gardner. She chose an excellent article that will help educate and alert us to the potentially fatal perioperative complication of bone cement implantation syndrome. It delves into the clinical presentation and anesthetic management of this syndrome. Enjoy! Here is a link to the article. Questions to engage discussion: 1) How often does BCIS (Bone Cement Implantation Syndrome) occur in femoral hip fracture repair using bone cement and what is the cause and clinical presentation with occurrence? 2) Discuss prevention techniques and management of BCIS as the rate of joint surgeries continue to increase along with the age of our patient population, and how this may affect your practice.
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Post by mcesaire on Jun 2, 2019 17:54:48 GMT -5
1. The incidence of the BCIS syndrome does not appear to be high, although as the article suggests it's likely missed since with many grade I patients it is just evidenced as a desaturation to 94% which can easily be attributed to something else. Either pulse oxygen failure or a transient disfunction of the probe. The use of a study that utilizes the TEE probe during these cases would be helpful. It was a bit frustrating to not see more prospective studies to truly identify the cause and corresponding treatment. 2. The best approach is a clear and detailed patient preoperative interview. The assessment of the patient and what cardiopulmonary issues place them at higher risk and which preventative techniques should be considered. The use of regional anesthesia versus general appears to be a serious consideration for patients who have existing lung disease. The ability to control the ETCO2 and make necessary interventions if BCIS is suspected is important. The availability of epinephrine and norepi appears to be quite vital as well as inotropes in the presence of RV dysfunction or failure. I thought this was a good article and I appreciated the information. Thanks, Marjorie
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Post by kels on Jun 6, 2019 16:11:57 GMT -5
Thankfully Bone Cement Implantation Syndrome is rare . The cause of BCIS seems to be related to elevated pulmonary artery pressure resulting in failure of the right ventricle however this is just a theory .Clinically BCIS seems to present from anything such as mild desaturation to hypotension to cardiac arrest.
Unfortunately there are no know techniques to 100 % prevent BCIS however recommendations to try and decrease the suggested 20 % occurrence rate include optimizing the pt as much as possible . Further research on this topic will be helpful to guide our anesthetic practices .
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Post by Sarah Rollison on Jun 11, 2019 7:01:31 GMT -5
1) BCIS is a rare complication of orthopedic surgery, however most BCIS cases occur during cemented hip hemiarthroplasty. BCIS can occur in two ways: the monomer-mediated model or the embolic model. The monomer model states that circulating methyl methacrylate (MMA) causes vasodilation which may result in a cardiopulmonary cascade. The embolic model states that emboli of fat, marrow, cement, bone, or platelet factors lodge in the right atrium after embolizing from the high intramedullary pressure after cement placement in the bone. Bone cement emboli cause vasoconstriction, increase pulmonary vascular resistance, decreased RV output, decreased CO, decreased SVR, and hypotension. Initial signs may include transient desaturation, bradycardia, and hypotension.
2) Although there are no absolute ways to prevent BCIS, certain steps can be taken to mitigate the risk. The first step is to perform a thorough preoperative assessment for individual patient risk of BCIS - those at high risk include >65 years old and those with numerous comorbidities such as cardiopulmonary diseases or severe osteoporosis. Additionally, those >85 years old are at greater risk for hemodynamic compromise if BCIS occurs, and proper monitoring should be in place. Intraoperatively, vigilance should be used during bone cement implantation and clear communication should occur during the event. Early hemodynamic changes of BCIS include bradycardia and hypotension, so EKG and NIBP should be continuously monitored. Additionally, volatile agents have been shown to cause more hypotension with BCIS, and should be avoided in high risk populations. In fact, regional anesthesia allows for continual mental status assessment of the patient during bone cement implantation. Patients should be euvolemic. I feel as though I already anticipate these steps in my current practice and I attempt to mitigate these risks as much as possible. However, this discussion has highlighted the importance of vigilant assessment and monitoring. Additionally, I may be more prone to suggest regional anesthesia for those with severe cardiopulmonary diseases such as COPD with hypoxia at baseline.
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Post by Ben Waldbaum on Jun 12, 2019 9:55:21 GMT -5
BCIS is very rare, and clinically has symptoms that vary from mild to the most severe such as cardiac arrest. Grade I is mild hypotension or hypoxia. Grade II is severe hypotension or hypoxia or LOC. Grade III is cardiovascular collapse requiring CPR.
Unfortunately there is no definitive way to prevent BCIS. However, as with any complication, steps can be taken to identify during the preop patients that are at risk and advise them of such a possibility, similar to how we advise prone patients to the possibility of post operative blindness. During the case, clear communication should occur prior to and during the cementing to allow for early identification of BCIS if it occurs. When possible regional anesthesia may be useful as a primary technique as it will allow for constant evaluation of mentation as long as the patient is not over sedated. Most importantly, the provider must be vigilant, which is true in any case.
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Post by Lu Lin on Jun 19, 2019 9:10:11 GMT -5
) BCIS is a rare complication of orthopedic surgery, however most BCIS cases occur during cemented hip hemiarthroplasty. BCIS can occur in two ways: the monomer-mediated model or the embolic model. The monomer model states that circulating methyl methacrylate (MMA) causes vasodilation which may result in a cardiopulmonary cascade. The embolic model states that emboli of fat, marrow, cement, bone, or platelet factors lodge in the right atrium after embolizing from the high intramedullary pressure after cement placement in the bone. Bone cement emboli cause vasoconstriction, increase pulmonary vascular resistance, decreased RV output, decreased CO, decreased SVR, and hypotension.
2) Although there are no absolute ways to prevent BCIS, certain steps can be taken to mitigate the risk. The first step is to perform a thorough preoperative assessment for individual patient risk of BCIS - those at high risk include >65 years old and those with numerous comorbidities such as cardiopulmonary diseases or severe osteoporosis. Intraoperatively, vigilance should be used during bone cement implantation and clear communication should occur during the event. Early hemodynamic changes of BCIS include bradycardia and hypotension, so EKG and NIBP should be continuously monitored. Additionally, volatile agents have been shown to cause more hypotension with BCIS, and should be avoided in high risk populations. In fact, regional anesthesia allows for continual mental status. Patients also should be euvolemic.
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nanci
Junior Member
Posts: 57
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Post by nanci on Jun 19, 2019 12:35:10 GMT -5
1) The study states BCIS is a reported complication of any cemented bone surgery and occurs in 20% of all femoral fracture repairs. Clinical presentation is noted to be hypoxia, hypotension, and an unexpected loss of consciousness that happens at cementation, prosthesis insertion, joint reduction or tourniquet deflation times. Cause could be from the embolus theory, role of histamine release theory, complement activation or some multimodal possibility- states that further research in this area is needed.
2) Prevention techniques and Management can be started with recognition of the risks during the preoperative assessment. Identification of high-risk patients and subsequent communication between providers to optimize high risk patients prior to surgery is the aim. Intraoperative use of invasive hemodynamic monitoring may be needed, consider using high oxygen concentrations especially at high-risk times (reaming, cementing, joint reduction, tourniquet deflation) and monitor the ETCO2 looking for unexplained drops. Pulse oximetry needed to detect hypoxia. EKG and BP monitoring to determine hemodynamic changes are needed. Keep fluid volumes normal as well.
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kty67
New Member
Posts: 22
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Post by kty67 on Jun 20, 2019 10:08:05 GMT -5
1. Luckily we don't see frequently BCIS in our practice, but maybe we do when we see drop in BP after tourniquet deflated with some ortho cases when cement was used. There is several models that explain BCIS including embolic model, histamine release, and multimodal models. I think it has a multimodal factors that it happens. 2. Earlier identification of high risk factors, detection of earlier signs of BCIS(drop in ETCO2 and/or drop in BP or HR), and fast initiation of supportive treatment is crucial to patients survival. it might include FiO2 100%, close monitoring of ECO2, IV fluids, and mainly close communication with surgical team.
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Post by Soo-Ok Kim on Jun 20, 2019 12:32:18 GMT -5
1. BCIS is rare phenomena with cemented hip arthroplasty although it can be missed with mild symptoms like Grade 1 presentation. Etiology isn't fully understood. But, several theories indicated BCIS is caused by vasodilatation with circulating MMA, RV failure by embolic event, anaphylactic reaction/histamine release, or combined multimodal theories.
2.Although BCIS may not be totally preventable, it is prudent to identify high risk patients preoperatively, to be vigilant to detect the s/s of that intraop, to initiate prompt treatment. Article suggested that arthroplasty with cement may have better overall long term outcome in bone mobility. So, it is important to bear in mind the risk/benefit ratio of using different surgical technique.
It was a great article to review this topic. Thanks.
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Post by Jackie Howell on Jun 20, 2019 13:51:41 GMT -5
1. The occurrence of BCIS is rare although it may be overlooked by symptoms that could be attributed to any sedation anesthesia case (desaturation, bradycardia, hypotension). BCIS can occur in two ways: the monomer-mediated model or the embolic model. As previously stated, there are several theories of how BCIS occurs (vasodilatation with circulating MMA, RV strain/failure by embolic event, anaphylactic reaction/histamine release).
2. Although there are no absolute ways of preventing BCIS, having a strong comprehensive assessment of your patient at baseline and identifying those at increased risks (existing pulmonary and cardiovascular disease, ortho procedures that will be using cement). Readily available epinephrine and norepinephrine for higher risk patients.
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Post by angie brooks on Jun 24, 2019 8:38:23 GMT -5
1) How often does BCIS (Bone Cement Implantation Syndrome) occur in femoral hip fracture repair using bone cement and what is the cause and clinical presentation with occurrence?
BCIS is currently reported in roughly 20% of all femoral fracture repairs. The cause is currently unknown, however there are several suspected theories including the monomer mediated theory, embolic model, histamine release and hypersensitivity and a combination of all of the above. Clinical presentation is usually hypoxia, hypotension, and an unexpected LOC at cementation, prosthesis insertion, reduction of the joint or tourniquet deflation. Rarely there is right ventricular failure related to increased pulmonary artery pressure.
2) Discuss prevention techniques and management of BCIS as the rate of joint surgeries continue to increase along with the age of our patient population, and how this may affect your practice.
Prevention of BCIS involves identification of high risk patients, preoperative optimization of patient risk factors and comorbidities, and good communication with the surgical team. As patients live longer, joint replacement surgery will continue to rise. Increasing joint surgery will increase the likelihood of BCIS occurring in patients. It is important to conduct more evidence based research to development guidelines for the identification and management of BCIS.
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Post by mary clothier on Jun 24, 2019 20:19:50 GMT -5
1) Impressive that the US has the highest incidence of TKR in the world, accounting for 9% of inpatient surgical admissions, and even more impressive a projected increase of 143% by the year 2050! Methyl methacrylate has always been associated with potentially significant hypotension when implanted in the joint, accompanying very noxious odor, and warmth to OR scrub touch and subsequent implantation of the joint components. Hip fractures which usually occur in our elderly population, who can also have multiple co-morbidities, are generally pinned avoiding methyl methacrylate and the rare and potentially fatal complication known as BCIS. Our potential to encounter BCIS, defined as hypoxia, hypotension, or both and/or unexpected LOC (regional case) occurring around the time of implantation of the joint cemented with methyl mathacrylate will rise with the projected increase of joints being done in the US,
2) As per our practice as CRNA's, our vigilance, attention to detail, and communication with our surgical team during joint implantation with methyl mathacrylate is critical! Strict attention to VS, as well as an increase in ETCO2 is most important to taking great safe care of our patients receiving THR! Our elderly patients with co-morbidities are potentially the most susceptible to BCIS syndrome, as well as the most fragile!
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Post by rboynton on Jun 25, 2019 9:40:06 GMT -5
Very interesting article. Something that as Anesthetists, we will have to be increasingly vigilent as the population of Babyboomers needing joint replacements increases. Resusitation of BCIS when it occurs is crucial to understand the process of Hypoxia, hypotension, possible loss of consciousness, RV failure, Etc and how to treat as needed. Also impressive in one study in 2016 that did a retrospective review of Spinal/epidural VS Epidural, is that 72% of all pts had some degree of BCIS. Proper pre op assessment and communication with all team members is a must to properly care for this pt group.
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Post by ucnavigeyca on Aug 19, 2019 2:16:43 GMT -5
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Post by egiualofeaba on Aug 19, 2019 4:19:38 GMT -5
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