[Crisis event] Sudden cement response syndrome during perianaesthesia

Sudden Cement Response Syndrome During Peri-anesthesia 01 1.
The occurrence and harm of Sudden Cement Response Syndrome during Peri-anesthesia.
It is an indisputable fact that China has entered an aging society
.

At the same time, with the rapid development of medicine and the rapid progress of science and technology, some old patients with bone and joint diseases that could not be treated can now be treated very well, especially when artificial joint replacement surgery can achieve ideal treatment results
.

However, some new thorny medical problems (such as bone cement response syndrome) have also emerged in this process, which have a great impact on the safety of elderly patients during surgery
.

The so-called bone cement response syndrome refers to the clinical manifestations of hypotension, arrhythmia, diffuse pulmonary microvascular embolism, shock, and even cardiac arrest and death after the implantation of bone cement in the human body during the perioperative period.
Kind of syndrome
.

1.
Artificial joint replacement and cement response syndrome in elderly patients (1) With the advent of aging society, with the increase of age, the functions of various organs and systems in the body gradually decline, and among these, osteoporosis and bone joints The disease is most prominent
.

The former is manifested as increased bone fragility, and fractures are prone to fractures under the action of external force; the latter is mainly manifested as chronic joint pain, joint dysfunction and loss
.

These lesions seriously affect the health and quality of life of the elderly in their later years
.

With the improvement of economic level, more and more elderly patients undergo artificial joint replacement, which can achieve good results for most elderly patients.
Therefore, this surgical treatment method has been widely promoted in clinical practice
.

Therefore, the objective needs of artificial joint replacement surgery in an aging society will become more and more conspicuous.

.

(2) Occurrence of bone cement response syndrome during artificial joint replacement in elderly patients: Because most elderly patients have osteoporosis, bone cement is often used in artificial joint replacement surgery
.

At present, the commonly used biological bone cements are divided into PMMA bone cements with poor biocompatibility and calcium phosphate bone cements with good biocompatibility
.

With the widespread use of bone cement, the effect of bone cement on the cardiovascular system, and the resulting "cement response syndrome", occur from time to time during surgery
.

After comprehensive literature reports, Woo et al.
found that the incidence of cardiac arrest due to bone cement syndrome was 0.
6% to 10%, and the case fatality rate was 0.
02% to 0.
5%
.

At present, both surgeons and anesthesiologists are highly vigilant about the occurrence of cement response syndrome during artificial joint replacement in elderly patients
.

2.
The manifestations and harms of bone cement response syndrome (1) Hypotension and shock: the most common, in early clinical observations, the probability of hypotension in patients after bone cement implantation is 1/3, and the average arterial pressure drop is 15 ~40mmHg
.

Clinical studies have found that the incidence of circulatory suppression, mainly hypotension, ranges from 26% to 95%
.

Some patients can recover on their own, and some patients require the intervention of boosting drugs to recover.
A few patients can develop refractory hypotension, until shock pulmonary edema and hypoxemia, or even death
.

The incidence is gradually increasing in patients aged> 65 years, especially in patients with preoperative hypovolemia and heart disease
.

(2) Arrhythmia: After bone cement implantation, patients may have bradycardia, tachycardia, ventricular arrhythmia, and even malignant arrhythmia, among which bradycardia has the highest incidence
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Clinically, it can be encountered that the heart rate of patients after implantation of bone cement drops from 80 to 90 beats per minute to 35 to 50 beats per minute, or even stops
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(3) Diffuse pulmonary microvascular embolism and deep vein thrombosis of the lower extremities: There is a report of a group of deep vein thrombosis of the lower extremities after total hip replacement.
The incidence of bone cement is as high as 33.
33% (34/102).
The bone cement group was only 6.
33% (5/79)
.

In 1979, Alexander et al.
found in 227 patients undergoing hip arthroplasty that the patients showed symptoms of pulmonary microembolism after bone cement and prosthesis implantation
.

The patient's arterial partial pressure of oxygen is reduced, and hypoxemia can continue after surgery, accompanied by increased serum esterase and decreased triacylglycerol, which may be related to bone cement and bone marrow fat entering the blood
.

In 1998, Tsujito et al.
reported that two cases (71 and 76 years) of bilateral hip replacement patients suffered from pulmonary embolism during bone cement implantation.
The patients quickly circulated failure and died within 3.
5 hours and 1 hour, respectively
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Postoperative pathological examination confirmed the presence of fat particles throughout the patient's pulmonary arterioles
.

In addition to bone cement entering the blood, the occurrence of pulmonary embolism may also be related to the intrusion of fat particles into the blood caused by bone cement compression and excessive intramedullary pressure during the implantation of the prosthesis
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Dahl et al.
found that after bone cement implantation, a large amount of its monomer enters the blood (30s up to 3599ng/ml) to activate the coagulation system, which has the possibility of generating thrombin in the pulmonary capillary bed
.

Others found that plasma thrombin complex (TAT) increased 2.
5 times and tissue fibrinogen activator activity increased 7 times after using bone cement
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In severe cases, it may cause diffuse intravascular coagulation
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Heisel et al.
found that as much as possible to clean the bone marrow cavity or not use bone cement, the embolism-like substances in the blood are significantly reduced
.

Fairman found in sheep animal experiments that methyl isobutyrate can cause pulmonary hypertension, increased pulmonary microvascular permeability, and increased pulmonary lymph flow
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Fabbri et al.
found that after bone cement caused pulmonary embolism, some patients showed a decrease in arterial blood oxygen partial pressure (a decrease of 11% to 38%) and a decrease in end-tidal carbon dioxide, and some patients showed a simple end-tidal decrease
.

(4) Cardiac arrest or death: There are scattered reports of cardiac arrest after bone cement implantation, while the mortality rate reported abroad is 0.
6% to 1%, and some are as high as 11.
5% (6/52)
.

Andersen reported 4 cases of cardiac arrest caused by bone cement, which may be related to the heat generation of bone cement polymerization, which caused venous air thrombosis caused by blood damage
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(5) Nervous system damage: The damage to the nervous system caused by bone cement is usually related to acute hypoxia and low blood perfusion
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Severe hypoxemia and hypoperfusion cause metabolic dysfunction in the brain tissue of patients, which in turn leads to diffuse brain tissue damage and a series of clinical syndromes of neurological abnormalities
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Different parts of the brain tissue have different tolerance to hypoxia
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The anterior sulcus is part of the original cortex and old cortex of the cerebral cortex.
It has important emotional regulation and higher cognitive functions, and is considered to be the basis of executive function nerves
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There are data reports that acute repeated hypoxia can cause serious damage to patients' brain nerve cells, and patients will have abnormal expressions in behavior, memory, cognition, personality, and emotions
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(6) Impairment of renal function: Impairment of renal function is also closely related to hypoxemia and hypoperfusion blood volume
.

Elderly people usually have a decline in renal function.
Hypoxemia and hypotension caused by bone cement response syndrome will increase renal vascular resistance, decrease renal blood flow and renal insufficiency, etc.

.

Therefore, it is very easy to cause renal failure in elderly patients
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02 2.
Analysis of the causes of sudden bone cement response syndrome during perianaesthesia 1.
Toxicity of bone cement monomer Bone cement liquid monomer (LMMA) can penetrate into human blood, and high concentration of bone cement liquid monomer not only inhibits myocardium Its toxic effect can also destroy some cells, release proteolytic enzymes, and dissolve cells and tissues.
In addition, the liquid monomer of bone cement can also act on the calcium channels of vascular smooth muscle, causing vasodilation, blood flow stasis and blood pressure drop
.

However, studies have shown that the systemic reaction toxicity caused by the liquid monomer of bone cement is very low, the myocardial inhibition is not obvious, and the lethal dose is very large
.

Only when the absorption of the liquid monomer of bone cement exceeds 35 times the normal allowable dose, does lung function decrease
.

Due to the decline in cardiopulmonary function and the regulation function of each system, immune function of elderly patients, or a certain dysfunction, or due to individual differences, the sensitivity to the liquid monomer of bone cement is different.
After being absorbed into the blood, it can cause a toxic reaction that seriously threatens the life of the patient
.

2.
Activation of the coagulation system Many scholars in the past believed that when bone cement is used, the liquid monomer of bone cement is absorbed into the blood, causing the release of tissue thrombin, platelet and fibrin aggregation, which leads to a series of complications such as various thrombus
.

However, experiments by Cenni et al.
confirmed that bone cement can also increase the activity of platelets to make it easier to form thrombus
.

And further studies have shown that platelets with enhanced activity have a synergistic effect with inflammatory reactions
.

Therefore, it can be known that when using bone cement, the activation of platelets in elderly patients with high coagulation tendency is more likely to cause various thrombosis in the patient, which directly threatens the life safety of the patient
.

3.
Pulmonary embolism caused by intramedullary hypertension was found through the study of a large number of deaths
.

The direct cause of death in patients with cement response syndrome is pulmonary embolism.
The emboli are mostly tiny emboli in the bone marrow cavity, such as fat particles, bone particles, bone marrow components and intramedullary fragments
.

In artificial joint replacements, especially knee replacements and total hip replacements, during reaming, marrow, and implantation of prostheses, the interstitial pressure of the femur or acetabulum increases.
When it is higher than the venous pressure, It can destroy the intramedullary veins, causing air, fat, bone marrow components, and bone marrow fragments to squeeze into the bone veins, enter the blood circulation, and form a pulmonary embolism
.

4.
Extensive expansion of peripheral blood vessels caused by histamine release.
Tryba et al.
, by measuring the serum histamine concentration before and after bone cement implantation, found that the increase in serum histamine concentration of all patients implanted with bone cement was greater than 0.
5~1ng/mL, and accompanied by There is a drop in systolic blood pressure
.

The use of H1 and H2 receptor antagonists before bone cement implantation can effectively prevent changes in cardiovascular function
.

Tryba et al.
believe that even moderate histamine release in elderly patients with cardiovascular disease and hypovolemia before surgery will cause serious and sometimes fatal cardiovascular complications, and fatal cardiovascular complications may occur.
There are many factors (such as hypovolemia, cardiac insufficiency, arrhythmia and histamine release, etc.
) associated with the combined effect
.

03 3.
Countermeasures for sudden bone cement response syndrome during perianaesthesia 1.
Adequate preoperative preparation.
Most elderly patients have cardiovascular disease, diabetes and lung damage, insufficient cardiopulmonary function reserve, and cannot tolerate severe hemodynamics.
Disorder
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Therefore, strengthening preoperative evaluation and preoperative preparation is an important part of improving the stress ability of cardiopulmonary function
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The blood volume of the patient should be appropriately increased before surgery
.

2.
Standard operation by surgeons Strictly abide by the procedures of bone cement infusion technology
.

Can be flushed with 1:400,000 adrenaline
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Thoroughly clean the bone marrow cavity, and pay attention to reducing the pressure of the medullary cavity during perfusion, thereby reducing the probability of pulmonary embolism
.

3.
Preventive drugs.
Add histamine receptor antagonists before surgery, inject glucocorticoid intravenously before implanting bone cement, or use corresponding blood pressure drugs for preventive treatment
.

4.
Place the inferior vena cava filter The inferior vena cava filter is the main method to prevent pulmonary embolism.
Before implanting bone cement, choose the contralateral femoral vein or the right subclavian vein approach, and place it at the lower pole and left and right sides of the kidney with the aid of fluoroscopy.
Between the bifurcations of the iliac vein, it can effectively filter the fat emboli that enters the blood due to the high pressure in the medullary cavity when the bone cement is implanted
.

5.
Strengthen monitoring Use transesophageal echocardiography to look directly at the embolus passing through the atrium
.

Others emphasize the routine use of floating catheters in elderly patients to detect changes in pulmonary circulation as soon as possible
.

Other routine tests such as electrocardiogram, oxygen saturation, end-tidal carbon dioxide, blood pressure, central venous pressure, etc.
are essential
.

Once the bone cement response syndrome occurs, the patient must first ensure the oxygen supply, and then determine whether there is a pulmonary embolism
.

The diagnosis and treatment of early pulmonary embolism are more conducive to improving the treatment rate of patients
.

When hypotension and other conditions occur, blood volume should be supplemented in time, and vasoactive drugs should be used at the same time
.

If necessary, 1 to 2 mg of phenylephrine or 0.
1 to 0.
2 mg of epinephrine can be used intravenously
.

Cardiopulmonary resuscitation should be performed in time if cardiac and respiratory arrest occurs
.

04 IV.
Thinking of sudden bone cement response syndrome during perianaesthesia 1.
Emergency treatment of bone cement response syndrome during artificial joint replacement in elderly patients during perianaesthesia.
In elderly patients during artificial joint replacement, once bone cement reaction is integrated Signs, we must first protect the patient’s oxygenation; then determine whether there is pulmonary embolism
.

The "gold standard" for the clinical diagnosis of pulmonary embolism is spiral CT pulmonary angiography.
However, during the operation, if the patient is critically ill and overemphasizes the improvement of various imaging examinations, the best time for treatment may be lost, and too much movement may cause deep The venous thrombosis falls off, causing irreparable and serious consequences
.

Therefore, early diagnosis and treatment of pulmonary embolism is more conducive to improving the treatment rate of elderly patients
.

(1) The basis for the preliminary diagnosis of pulmonary embolism during artificial joint replacement surgery in elderly patients
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① For patients undergoing intraspinal anesthesia, if they have difficulty breathing, chest pain, syncope, hemoptysis, etc.
, emergency tracheal intubation should be performed immediately to find out the cause and deal with it symptomatically
.

②For patients with general anesthesia, if there are no obvious reasons for airway hypertension, decreased blood pressure, increased heart rate, decreased blood oxygen saturation, and decreased end-respiratory CO2, pulmonary embolism should be suspected and further examinations should be performed if other possible conditions are excluded.
Disposal
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(2) The prompting function of the further examination content of pulmonary embolism during artificial joint replacement surgery in elderly patients
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①Blood gas analysis showed hypoxemia, hypocapnia, and increased difference in oxygen partial pressure between alveolar and arterial blood
.

②Bedside ECG showed SⅠQⅢTⅢ, echocardiogram showed enlarged right atrium and right ventricle and pulmonary hypertension
.

③The content of D-dimer is greater than 500ug/L
.

④The brightness of the lung field in chest X-rays increased
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If the above conditions are met, early diagnosis of pulmonary embolism can be made, and pulmonary embolism treatment can be performed quickly
.

The treatment of pulmonary hypertension is performed first, followed by thrombolysis, anticoagulation, and symptomatic treatment
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After the patient's vital signs stabilized, he was sent to the ICU and received ventilator treatment until the patient got better
.

2.
Thinking of the emergency clinical path of bone cement response syndrome during artificial joint replacement of elderly patients.
At present, the medical management department or the medical association has issued a large number of clinical paths for clinical emergent high-risk events, but it is related to artificial joint replacement of elderly patients.
The author has not reported the emergency clinical path of bone cement response syndrome at this time
.

In the emergency clinical pathway of cement response syndrome during artificial joint replacement of elderly patients, we believe that the following points must be included
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(1) Once bone cement syndrome occurs, the anesthesiologist should immediately organize emergency rescue; all medical staff must stick to their posts, put the safety of patients' lives as the first priority, and ensure the smooth progress of all rescue tasks
.

(2) Immediately consult the superior doctor or the head of the reporting section.
The superior doctor or section director must visit the front line in person to deploy personnel and direct the scene
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(3) If other department personnel are required to assist in the rescue, the medical department must be notified as soon as possible, and the medical department will deploy relevant personnel to assist in the rescue
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(4) The doctor in charge shall closely observe and record at any time, and submit materials to the medical department when necessary
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(5) Communicate with the patient’s family in a timely manner, tell the situation, and sign the emergency rescue agreement to reduce postoperative medical disputes
.

3.
Thinking of other issues The occurrence of cement response syndrome during artificial joint replacement in elderly patients seriously endangers the patient’s life and safety.
We must use correct clinical thinking, establish corresponding prevention and treatment strategies, and do our best to avoid its harm
.

However, in actual clinical practice, we must seriously consider the following questions: ① Do anesthesiologists and surgeons have a common understanding and mental preparation for this issue? ②How to make the correct diagnosis of bone cement response syndrome and deal with it urgently during artificial joint replacement in elderly patients? ③Should there be an admission system for the anesthesiologists and surgeons involved in this type of surgery? ④Whether the quality and use technology of bone cement in artificial joint replacement for elderly patients can formulate strict and uniform national standards? ⑤How to resolve and deal with medical disputes caused by the occurrence of cement response syndrome during artificial joint replacement surgery in elderly patients and cause adverse consequences, and how to protect the legitimate rights and interests of both doctors and patients? 05 5.
Typical case sharing of sudden cement response syndrome during peri-anaesthesia.
Patient, 63 years old, weight 68kg, ASA Ⅲ, was admitted to the hospital for a fracture of the right femoral neck, and under general anesthesia 5 days later, the right femoral head was replaced under general anesthesia
.

The patient had prostatitis, enlarged prostate for 8 years, frequent urination, urgency, and incomplete urination
.

The patient has a history of hypertension and coronary heart disease for 12 years, and the highest blood pressure is 165/110mmHg, without systemic treatment
.

The breath sounds of both lungs were clear on auscultation, and there was no obvious abnormality on X-ray examination
.

30 minutes before surgery, intramuscular injection of diazepam 5mg and tomorodine 0.
3mg, routine monitoring after entering the operating room: no obvious abnormalities in electrocardiogram, blood pressure 141/93mmHg, pulse 89 beats/min, SpO296%
.

Anesthesia induction medication: midazolam 3mg, fentanyl 0.
2mg, etomidate 14mg, vecuronium 7mg intravenously, tracheal intubation machine controlled breathing, tidal volume 560ml, respiratory rate 12 times/min, blood pressure 135/ 92mmHg, heart rate 83 beats per minute
.

Intravenous continuous pumping of propofol (TCI target concentration of 3.
5ug/ml), isoflurane inhalation maintained 1% to 1.
5% adjustment, intravenous inhalation combined to maintain anesthesia
.

Constant infusion of remifentanil 0.
12ug/(kg.
min), intermittent injection of vecuronium to maintain muscle relaxation
.

The blood pressure is maintained at 130/90mmHg, and the heart rate is around 85 beats per minute
.

During the operation, the crystal-to-gel ratio was 1:1 infusion, the crystal liquid was selected as Ringer lactate solution, and the colloidal liquid was selected as Hess
.

60 minutes after the operation, the vital signs were stable
.

Five minutes after the bone cement was inserted into the medullary cavity, the heart rate increased from 90 beats/minute to 140 beats/minute, the blood pressure dropped from 132/79mmHg to 89/52mmHg, SpO286%, the ST segment moved down significantly, and ventricular arrhythmia , Frequent premature ventricular contractions
.

Then the heart rate slowed down, the operation was stopped, a single injection of dopamine 3mg was given intravenously, the blood pressure rose to 102/63mmHg, and the heart rate was about 120 beats/min.
At this time, the ST segment was elevated compared to the previous one, and ventricular still occurred frequently.
Pre-term contraction
.

Then he was given 2mg of dopamine intravenously, the blood pressure rose to 140/90mmHg, the heart rate was about 120 beats/min, and the ventricular premature contractions were as few as 5 beats/min
.

For fast heart rate, intravenous administration of esmolol 20mg, blood pressure dropped to 105/65mmHg after administration, heart rate was about 90 beats/min, ST segment moved down significantly, and ventricular premature contraction increased to 7-8 beats/min
.

A single intravenous injection of 3 mg of dopamine, 50 mg of esmolol into 50 ml of normal saline pump injection, blood pressure maintained at 130/80 mmHg, heart rate around 90 beats/min, ST segment gradually returned to baseline, occasional ventricular premature contraction 1~2 Times/min
.

At the end of the operation, the patient resumed spontaneous breathing.
The tracheal tube was removed.
The blood pressure was 130/80mmHg, the heart rate was 95 beats/min, and the blood oxygen saturation was 98%.
The ECG still showed a slight downward shift of ST segment and occasional ventricular premature contractions
.

Six hours after the operation, the ST segment of the ECG had returned to baseline, and occasionally ventricular premature contractions occurred at 1 to 2 times/min
.

After 24 hours of follow-up, the vital signs were stable
.

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