Bone cement implantation syndrome.pptx (856Kbytes)


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Bone cement implantation syndrome.pptx (856Kbytes)

  1. 1. Bone cement implantation syndrome (BCIS)<br />Department of Anaesthesia, <br />University Hospital of South Manchester<br />Br J Anaesth 2009; 102: 12–22<br />전공의 3년차 노지성<br />
  2. 2. Background<br />BCIS <br />cause of morbidity and mortality in cemented hip arthroplasty<br />Increase in the number of ASA II and III patients <br /> undergoing a THR in recent years<br />Between April 2006 and March 2007보고:<br />length ofstay<br />9.8 days (cemented primary THR) vs. 8.6 days(uncemented procedure) <br />mortality after cemented and uncemented primary THR <br />2.3% and 1.6%<br />2000~3 National Institute for Health and Clinical Excellence (NICE) guidelines<br />long-term viability(cemented prosthesis):better results<br />
  3. 3. Search strategy<br />Medline search for the phrases; <br />bone cement, bone cement implantation syndrome, arthroplasty, hip replacement, complications, methyl methacrylate (MMA), and monomer<br />Definition<br /><ul><li>No agreed definition
  4. 4. a number of clinical features: </li></ul> hypoxia, hypotension, cardiac arrhythmias, increased pulmonary vascular resistance (PVR) and cardiac arrest-hip arthroplasty에만 국한된 것은 아님<br /><ul><li>Occur at one of the five stages in the surgical procedure;‘pericementation period’</li></li></ul><li>Proposed definition of BCIS<br />cemented bone surgery.<br />occurring around the time of cementation, prosthesis insertion, reduction of the joint or, occasionally, limb tourniquet deflation<br />hypoxia <br />hypotension <br />unexpected LOC <br />Proposed severity classification of BCIS<br /><ul><li>Grade 1: moderate hypoxia (SpO2<94%) </li></ul> or hypotension (fall in SBP > 20%)<br /><ul><li>Grade 2: severe hypoxia (SpO2<88%) </li></ul> or hypotension (fall in SBP > 40%) or unexpected LOC <br /><ul><li>Grade 3: cardiovascular collapse requiring CPR.</li></li></ul><li>Incidence<br />not possible to draw true incidence : under-reported, lack of a standard definition<br />A study of 48 patients: 1 patient (2%) suffered significant hypotension and 8 patients (17%) developed significant desaturation<br />A study of 55(cemented long-stem hip arthroplasty): hypotension in 38%, desaturation in 25%.<br />mortality data <br />Only three large case during cemented THR : 0.11%<br />The largest study in 1999<br />23 in 23,077 : intra-operative deaths patients (cemented arthroplasty)<br />11 deaths in 11,655 cemented total hip arthroplasties, <br />12 during 2,814 cemented hemiarthroplasties<br />Because of cardio-respiratory problems during cementation<br />
  5. 5. Clinical features<br />Wide spectrum of severity<br />in the peri-cementation period <br />significant, transient reduction in SpO2 ,BP<br />smaller proportion: profound intra-operative cardiovascular changes, which may proceed to arrhythmias, shock or cardiac arrest<br />embolization of femoral canal contents to the cerebral circulation post-operative delirium<br />A case report- BCIS during hemiarthroplasty<br />Intra-operative cardiac arrest후 의식 회복이 안되어 MRI F/U:<br />suggestive of multiple cerebral fat emboli<br />
  6. 6. Etiology and pathophysiology 1<br />not fully understood<br />Proposed several mechanisms<br />Initial theories: focused on the release into the circulation of MMA cement monomer<br />More recent research : the role of emboli formed during cementing and prosthesis insertion<br />histamine release, complement activation, and endogenous cannabinoid-mediated vasodilatation<br />
  7. 7. Monomer-mediated model<br />BCIS에서 혈역학적 변동은 cementing시 monomer에 의해 일어난다는 이론.<br />하지만 이는 monomer의 직접적인 작용이라기 보다는 intramedullary pressure(IMP)결과로 인한 것이며, 이로써 embolization을 일으킨다. <br />Embolic model<br />Echocardiography: Embolism발견<br />Post-mortem studies: pulmonary embolization<br />물리적인 효과와 mediator 방출의 결과<br />pulmonary vascular tone을 증가mechanicalembolization<br />Mechanism of emboli formation<br />cementation 과 prosthesis insertion 때 IMP 증가, cement의 온도가 높아져 prosthesis 와 bone, trapping air 와 medullary contents 사이의 공간이 확장되어 혈류로 밀려 들어간다.<br />Cementation은 cement gun 이나손으로 femoral canal을 packing pressures가 생성된다.(Table 3)<br />Etiology and pathophysiology 2<br />
  8. 8. Etiology and pathophysiology 2<br />
  9. 9. Transosophageal echocardiography (TOE)<br />emboli in the heart using TOE and these vary greatly in size and number (Fig. 1)<br />A study<br />emboli in 47 out of the 48 patients.<br />appearance of multiple small emboli as a ‘snow flurry’<br />Emboli greater than 10 mm: 1/3에서 발견됨<br />most marked during reaming of both the femur and acetabulum, and during insertion of the femoral component and reduction of the hip joint<br />Etiology and pathophysiology 3<br />
  10. 10. Fig. 1 (A) Small emboli ( <5 mm) filling less than half of the right atrium.<br /> (B) Medium-sized emboli (5–10 mm, arrowed) and small emboli filling more than half of the right atrium.<br /> (C) Small emboli ( <5 mm) completely filling the right atrium, multiple paradoxical emboli in left atrium. <br /> (D) Large emboli ( >10 mm) in the right atrium with delayed <br /> passage at the tricuspid valve.<br />
  11. 11. Evidence of emboli at autopsy<br />marrow, fat, bone emboli, and MMA microparticles in the lungs<br />fat emboli: brain, kidneys, and myocardium<br />The link between IMPand embolization<br />embolization 은 IMP와 비례한다.<br />상한효과도존재함<br />즉, 이런 현상은 femoral canal 에 존재하고 있는 debris 양이 제한 때문이었다. (Fig. 2).<br />Etiology and pathophysiology 4<br />
  12. 12. Fig 2 . Number of fat emboli in the lungs (area of 1200 mm2) <br /> and the maximum mean IMP over a 10-s interval. <br />Reproduced with permission from Waddell and Byrick<br />
  13. 13. The haemodynamic effects of embolization<br /> embolize to the lungs, heart or paradoxically to the<br /> cerebral and coronary circulations<br /> hypoxia & hypotension (because of RV dysfunction)<br />Mediator release from emboli<br />damage of endotheliumreflex vasoconstriction or release of endothelial mediators<br />embolic material may release vasoactive or pro-inflammatory substances increase PVR<br />Etiology and pathophysiology 5<br />
  14. 14. Fig 3. Pulmonary vessel with embolus comprising fat, platelets, fibrin & marrow debris. <br /> Reflex vasoconstriction and endothelial production of endothelin 1.<br /> Release of vasoconstriction mediators; platelet derived growth factor (PDGF), serotonin <br /> (5-HT), thromboxane A2 (Tx-A2), platelet activating factor (PAF), adenosine <br /> diphosphate (ADP). <br />(3) Vasoconstriction attributable to non-cellular components of embolus including thrombin.<br />
  15. 15. Problems with the embolic model<br />Embolization이 항상 혈역학적 변동과 연관된 것은 아니고,<br />Embolism의 정도가 hypotension 이나 hypoxemia의정도와 관련성이 부족<br />또한 TOE study에서 보면 embolic event는 보이나, V/Q mismatch는 정상으로 유지된다.<br /><ul><li>micro-embolism 은 BCIS에서 기여인자 이긴 하나, </li></ul> 아마도 다른 mechanisms도 공존할 것으로 추측<br />Histamine release and hypersensitivity<br />1972년에 발표된 BCIS의 치명적인 case에서는 Anaphylaxis (Type 1 hypersensitivity)가 복합적으로 관련되었을 가능성이 있었다.<br />또한 cementation 을 받는 저혈압 환자에서는 plasma histamine concentration이 증가<br />Etiology and pathophysiology 6 <br />
  16. 16. Complement activation<br />cemented hemiarthroplasty에서 C3a와 C5a 수치 증가가 증명<br />Multimodal model<br />clinical features may depend upon the individual’s physiological response<br />patient’s pre-existing co-morbidities may alter the clinical features of BCIS<br />Etiology and pathophysiology 7<br />
  17. 17. Patient risk factors & Surgical factors<br />old age<br />poor pre-existing physical reserve<br />impaired cardiopulmonary function<br />Osteoporosis, bony metastases<br />concomitant hip fractures<br />particularly pathological or intertrochanteric fractures<br />PFO or ASD emboli and neurological sequelae 증가 <br />
  18. 18. Anaesthetic risk reduction<br />ASA score of three or over<br />14% of primary hip arthroplasty<br />26% of revision procedure<br /> full investigation of co-morbidity and pre-optimization이필요.<br />Depending on individual patient and the type of prosthesis<br />Avoiding i.v. depletion-reduce the extent of the haemodynamic changes in BCIS<br />haemodynamic monitoring<br />CVP: volume optimization,<br />pulmonary artery catheter, TEE in high risk patients.<br />
  19. 19. Surgical risk reduction<br />several modifications in the surgical & anaesthetic technique<br />Medullary lavage<br />good hemostasis before cement insertion <br />minimizing the length of the prosthesis<br />venting the medulla<br />reduces the risk of an air embolus<br />But, risk of femoral fracture<br />Retrograde cement insertion<br />mixed cement in a partial vacuum<br />
  20. 20. Management<br />마취의사와 수술의사와의 Communication 중요<br />the early indication of BCIS <br />A fall in ETCO2<br />Esophageal Doppler measurements<br />Regional A. : dyspnea and altered sensorium<br />Recommendations <br />경험과 case reports ,basic physiological principle 의해 판단<br />a cemented prosthesis should be avoided in patients at high risk of BCIS<br />BCIS 가 의심될 경우,<br />oxygen concentration 100% 유지<br />be treated as RV failure<br /><ul><li>pure alpha agonist ora mixed alpha and beta receptor agonist
  21. 21. Hemodynamic instability</li></ul>Sympathetic a1 agonists (first-line agent)<br />if there is insufficient pre-load : aggressive resuscitation with i.v. fluids <br />central venous catheter-CVP monitoring<br />
  22. 22. 감사합니다<br />