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Cementing syndrome - Hip under spinal (Recognition and action…
Cementing syndrome - Hip under spinal
Recognition and action
This is an emergency situation requiring immediate and concurrent management and diagnosis
Exacerbated by:
Poor positioning: May be in lateral decubitous position making resus more difficult
Comorbidities: Severe RA increases: likleihood of difficult airway and reducced cardiac and resp reserve
Characterised by:
Hypoxia, hypotension, arrhythmia, Pulm HTN, LOC or Cardiac Arrest
Wide spectrum of severity
TOE: increased PVR, R heart dysfx, bulging septum, L heart dysfx, decreased CO
Decreased MAP
Occurs at: femoral reaming, cement implantation, insertion of prosthesis, joint reduction, tourniquet deflation
Classification: Gd 1: moderate hypoxia (sats<94 / BP drop> 20%), GD 2: severe hypoxia (sats<88, BP drop >40%, LOC), Gd 3: CVS collapse
Immediate maangement
Confirm LOC
Alert surgeon, call for help
Cease sedatives
Review other physical parameters
Assess circulation (HR, MAP)
If absent, commence ALS with posterior reinforcement (CPR, defib, drugs) and need to turn supine asap
Fluid bolus and vasopressor to restore preload
Differential diagnosis
Surgical
Embolic causes: fat, cement (bone cement implantation syndrome)
Blood loss
Non surgical
Hypoxia: obstruction, oversedation, aspiration
Hypercarbia: oversedation, worsening pulmonary HTN
Cardiac dysfunction: IHD, acute RV or LV failure, arrhythmia, APO
CNS: CVA
Electrolyte: hypoglycaemia, hyponatraemia
Anaphylaxis
Drug error ? inadvertant relaxant
Delayed onset high spinal
Investigation
ABG: Pa02, PaCO2, acid-base, HB, BSL, electrolytes
Formal FBE (Hb, plts), UEC, troponin, coags
ECG
Ongoing management
ALS with attempt to restore circulation, then post resus care
Definitive airway
Ongoing fluid and inotrope management
Consider wake up and assess neuro fx or CTB and echo first
ICU post op
Surgery
Completion of surgery as rapidly and safely as possible
Prevention
Surgical: reduce risk
Medullary lavage
Good haemostasis before cementing
Minimising length of prosthesis
Non cementing prosthesis
Venting medulla
Cement gun (more even distribution)
Anaesthetic
?volatile = greater haemodynamic changes for a given embolic load in animal study
Increase fiO2 at time of cement
Avoid intravascular volume depletion
High risk patient should have invasive monitoring