If Bone Cement Implantation Syndrome is suspected, immediate management is crucial, as the syndrome is reversible and generally time-limited. The initial steps include securing the airway, increasing the inspired oxygen concentration to 100%, and monitoring ETCO2 accurately. In cases of grade 3 BCIS, initiating cardiopulmonary resuscitation is critical, with epinephrine as the vasopressor of choice for collapse. Anesthesia providers should reduce or pause vasodilating anesthetic agents such as propofol or a deep volatile concentration if hemodynamic stability is compromised, and should tell the surgeon at once so that pressurization can stop.
It is important to treat cardiovascular collapse as right ventricular (RV) failure within the context of BCIS. This treatment may involve administering intravenous fluids to maintain normovolemia and using pulmonary vasodilators, such as inhaled nitric oxide, to reduce pulmonary artery pressure if hypoxemia and right ventricular dysfunction are observed. Inotropic agents like dobutamine may be necessary to support RV contractility. Direct-acting α-1 agonists can also stabilize hemodynamic parameters, particularly in cases of bradycardia and hypotension, although caution is advised when using sympathomimetics in the presence of pulmonary vasoconstriction.
Pharmacologic Interventions
No drug has been shown to prevent BCIS, and none of the agents below has proven benefit once it occurs; they appear in the literature as adjuncts argued from the proposed mechanisms, and oxygen, volume, vasopressors, and right ventricular support remain the treatment. Pharmacological management may involve the administration of ondansetron, a 5-HT3 receptor antagonist, to mitigate the effects of serotonin that can contribute to pulmonary vasoconstriction during BCIS. Pre- and intraoperative histamine receptor antagonists may also be employed to counteract inflammatory responses and potential hypersensitivity reactions triggered by bone cement. Corticosteroids may be beneficial for addressing inflammatory or anaphylactoid reactions, particularly in patients with preexisting allergies or inflammatory comorbidities. The administration of non-steroidal anti-inflammatory drugs (NSAIDs) may further help in controlling inflammatory responses associated with BCIS.
In cases where metabolic acidosis is evident, sodium bicarbonate can be administered to correct acid-base imbalances. Furthermore, intraoperative fluid resuscitation with blood products is advisable, especially in elderly patients who may present with anemia, as this condition can further impair the circulation's oxygen delivery capacity. Monitoring through central venous pressure lines can guide fluid therapy and vasopressor or inotrope administration. Following surgery, intensive care unit management may be necessary for patients with BCIS to ensure comprehensive monitoring and supportive care.
| Step | Action |
|---|---|
| Airway and oxygen | Secure the airway, increase inspired oxygen to 100%, and monitor ETCO2 accurately |
| Grade 3 BCIS | Begin cardiopulmonary resuscitation |
| Anesthetic agents | Reduce or discontinue propofol if hemodynamic stability is compromised |
| Volume | Intravenous fluids to maintain normovolemia, guided by central venous pressure monitoring, with blood products in elderly patients whose anemia already impairs oxygen delivery |
| Pulmonary vasodilation | Inhaled nitric oxide to lower pulmonary artery pressure when hypoxemia and right ventricular dysfunction are present |
| Circulatory support | Dobutamine to support right ventricular contractility, and direct-acting α-1 agonists for bradycardia and hypotension, with caution about sympathomimetics during pulmonary vasoconstriction |
| Inflammatory and hypersensitivity response | Ondansetron for serotonin-driven pulmonary vasoconstriction; histamine receptor antagonists, corticosteroids and NSAIDs for inflammatory or anaphylactoid reactions |
| Metabolic acidosis | Sodium bicarbonate to correct acid–base imbalance |
| After surgery | Intensive care management for continued monitoring and supportive care |
