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Anaesthesia type and cement reactions in hip fracture surgery

Last post 05 Feb 2019, 7:35 PM by Stuart White. 0 replies.
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  •  05 Feb 2019, 7:35 PM 2730

    Anaesthesia type and cement reactions in hip fracture surgery

    Bone cement implantation syndrome (BCIS) occurs in about 20% of patients undergoing cemented prosthesis insertion for hip fracture repair, requiring cardiopulmonary resuscitation in ~2.5% of cases [1]. Neither the Association of Anaesthetists safety guideline on BCIS [2], nor the recently published International Fragility Fracture Network consensus statement on the principles of anaesthesia for hip fracture [3], or the secondary analysis of Anaesthesia Sprint Audit of Practice (ASAP2) data [4] which inform these, or even Donaldson et al.’s seminal paper on BCIS [5], provide any indication about whether the mode of anaesthesia used might be protective. 


    We hypothesized that general anaesthesia involving tracheal intubation and positive pressure ventilation might be associated with a reduced prevalence of clinically apparent BCIS compared with a supraglottic airway device and spontaneous ventilation, consequent to improved ventilation/perfusion matching. 

    We interrogated the ASAP 2 dataset [4] to test this hypothesis, extracting data for patients receiving cemented prosthesis insertion (hemiarthroplasty/total hip arthroplasty) in whom BCIS was recorded (yes/no) and for whom type of anaesthesia was recorded (general anaesthesia: intubated/mechanically ventilated or supraglottic airway/self-ventilating, or regional anaesthesia). 


    Complete datasets were recorded for 5029 patients, 760 (15.1%) of whom experienced BCIS. Of 2371 patients administered general, without additional spinal, anaesthesia there was no statistical difference in BCIS prevalence between patients who were mechanically ventilated and those who were self-ventilating (224/1375 (16.3%) vs 174/822 (17.5%), two-tailed Fisher’s exact p=0.4694). However, there was a statistically significant reduction in BCIS prevalence in patients receiving only spinal anaesthesia compared with those receiving only general anaesthesia (327/2391 (13.7%) vs 398/2371 (16.8%), two-tailed Fisher’s exact p=0.0028). The prevalence of BCIS in patients administered both spinal and general anaesthesia was 35/267 (13.1%).


    These observational data are hypothesis generating. Previous research has found greater haemodynamic variability for the same (BCIS) embolic load in dogs administered inhalational compared with intravenous anaesthesia, attributed by the authors to an inadequate heart rate response or impaired vasoconstriction under physiological stress [6]. Contrary to our findings, Svartling et al. suggested that cementation activates the adrenocortical response, which is suppressed by spinal, but not general, anaesthesia in humans, maintaining blood pressure in patients administered the latter [7]. Interestingly, patients administered combined spinal/general anaesthesia had an associated BCIS prevalence closer to that of spinal, rather than general, anaesthesia, suggesting a greater effect of the former on BCIS pathophysiology. These studies, together with our data, support Donaldson et al.’s assertion that BCIS results from a complex aetiological interplay between embolisation, immune reactivity and blunted patient homeostasis related to hip fracture pathology, surgery and anaesthesia [5].  


    A ‘simple’ solution to the problem of BCIS, and its associated morbidity and mortality, would be to avoid cementing the prosthesis in position, through the development of cost-equivalent non-cemented prostheses providing similar re-operation and mortality rates, and pain-free mobility after surgery. In the interim, and given the relative prevalence of BCIS in the 70,000 patients annually who fracture a hip in the UK, it would seem sensible to conduct a randomised 3 group comparison of anaesthetic technique (spinal anaesthesia vs. general anaesthesia ventilated vs. general anaesthesia self-ventilating) on BCIS prevalence, in order to more accurately inform future iterations of the Association of Anaesthetists guidance [2]. 


    S. M. White

    Royal Sussex County Hospital,

    Brighton, UK.

    R. Griffiths

    Peterborough and Stamford Hospitals NHS Trust,

    Peterborough, UK.

    Email: stuart.white@bsuh.nhs.uk


    No external funding declared. SW is an Editor of Anaesthesia. 



    1. National Hip Fracture Database. Anaesthesia Sprint Audit of Practice (ASAP). 2014. http://www.nhfd.co.uk/20/hipfractureR.nsf/4e9601565a8ebbaa802579ea0035b25d/f085c664881d370c80257cac00266845/$FILE/onlineASAP.pdf (accessed 01/02/2019).

    2. AAGBI/BOA/BGS Working Party on Bone Cement Implantation Syndrome. Safety guideline: reducing the risk from cemented hemiarthroplasty for hip fracture 2015. Anaesthesia 2015; 70: 623-6.

    3. White SM, Altermatt F, Barry J et al. International Fragility Fracture Network consensus statement on the principles of anaesthesia for patients with hip fracture. Anaesthesia 2018; 73: 863-74.

    4. White SM, Moppett IK, Griffiths R, et al. Secondary analysis of outcomes after 11,085 hip fracture operations from the prospective UK Anaesthesia Sprint Audit of Practice (ASAP 2). Anaesthesia 2016; 71: 506-14.

    5. Donaldson AJ, Thomson HE, Harper NJ, Kenny NW. Bone cement implantation syndrome. British Journal of Anaesthesia 2009; 102: 12-22.

    6. Guest CB, Byrick RJ, Mazer CD, Wigglesworth DF, Mullen JB, Tong JH. Choice of anaesthetic regimen influences haemodynamic response to cemented arthroplasty. Canadian Journal of Anaesthesia 1995; 42: 928-36.

    7. Svartling N, Lehtinen AM, Tarkkanen L. The effect of anaesthesia on changes in blood pressure and plasma cortisol levels induced by cementation with methylmethacrylate. Acta Anaesthesiologica Scandinavica 1986; 30: 247-52.

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