This study was to investigate the influence of bone cement implantation on haemodynamics and the preventive effect of epinephrine hydrochloride on pulmonary embolism in elderly patients with cemented semihip replacement. 128 patients were retrospectively analyzed. The patients were treated with (group A, 64 cases) or without (group B, 64 cases) epinephrine hydrochloride saline. The monitoring indicators included systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), and pulse oxygen saturation (SPO2). The indicators of the two groups were compared before and 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 minutes after bone cement implantation. Analysis of variance and SNK-q test were used for the statistical analysis. Blood pressure and SPO2 of group B decreased with statistical difference (
Femoral neck fractures comprise 50% of geriatric hip fractures and are associated with radial and humeral fractures [
It is reported that, in cemented hemiarthroplasty, the right ventricular hemodynamics changed when the prosthesis is inserted into the femur. It could be detected by right ventricular ejection fraction and transesophageal dynamic electrocardiography monitoring. However, most of the patients had no clinical symptoms of hemodynamic changes, with only a small number of patients showing bone cement implantation syndrome (BCIS) [
It has not been extensively studied how the haemodynamics change during bone cement implantation in elderly patients with femoral neck fracture and semiarthroplasty. The purpose of this study was to investigate the influence of bone cement implantation on haemodynamics and the preventive effect of epinephrine hydrochloride on pulmonary embolism in elderly patients with cemented semihip replacement.
The study was approved by the Ethics Committee of Third Hospital of Hebei Medical University. All signed informed consent forms were obtained. 128 patients (54 males, 74 females; average age of 83.5, range of 75–92) with femoral neck fracture who were admitted to the hospital from January 2008 to January 2012 were enrolled in the study. The inclusion criteria were patients with Garden 3 or Garden 4 of acute hip fractures and patient age >70. The patients with hypertension, diabetes, or lung disease were excluded.
All patients underwent bone cement-hemiarthroplasty using Palacos bone cement (Heraeus Medical, Berlin, GER). The patients were treated with epinephrine hydrochloride saline (Hefeng Pharmaceutical Co., Ltd., Shanghai, China) (group A, 64 cases) or not treated (group B, 64 cases).
Hemiarthroplasty was performed as described previously [
The electrocardiogram monitor (M8004A, Philips Healthcare, Netherlands) was used to detect the blood pressure, heart rate (HR), electrocardiogram (ECG), and pulse oxygen saturation (SPO2) in all patients. The monitored indicators included the systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), HR, and SPO2. The values before using bone cement and 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 min after bone cement implantation were recorded.
All data was analyzed by SPSS 13.0 software. The indicators at different time points were analyzed by multifactor analysis of variance (ANOVA). If it was statistically significant, the SNK-q test was used for comparisons between the two groups.
All patients showed decrease of blood pressure 1 min after implantation. 2–6 min after implantation, the blood pressure began to decrease significantly (SBP and DBP,
As for blood pressure decrease (Figure
The change of hemodynamics after implantation of bone cement in group B (
SBP (mmHg) | DBP (mmHg) | MAP (mmHg) | HR (BPM) | SPO2 (%) | ||
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Before using bone cement | 130.26 ± 19.04 | 82.74 ± 7.75 | 98.58 ± 11.51 | 72.69 ± 10.19 | 99.65 ± 0.35 | |
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After using bone cement (min) | 1 | 127.26 ± 18.06 | 81.55 ± 9.81 | 96.79 ± 12.56 | 73.78 ± 11.19 | 98.07 ± 1.22 |
2 | 126.67 ± 16.86 | 76.96 ± 10.84 | 93.53 ± 12.85 | 74.64 ± 12.69 | 97.28 ± 1.39 | |
3 | 115.28 ± 09.67 | 68.45 ± 9.59 | 84.06 ± 9.62 | 75.99 ± 10.24 | 95.65 ± 1.30 | |
4 | 102.76 ± 09.36 | 61.55 ± 9.81 | 75.29 ± 9.93 | 81.66 ± 10.93 | 92.80 ± 1.08 | |
5 | 102.98 ± 09.95 | 59.45 ± 10.01 | 73.96 ± 10.03 | 83.31 ± 10.73 | 92.30 ± 1.39 | |
6 | 101.38 ± 09.60 | 58.75 ± 9.28 | 70.46 ± 9.39 | 85.99 ± 11.06 | 93.30 ± 1.57 | |
7 | 117.05 ± 10.03 | 65.25 ± 11.29 | 82.52 ± 11.71 | 78.34 ± 10.42 | 97.48 ± 1.46 | |
8 | 120.34 ± 05.56 | 73.21 ± 10.77 | 88.92 ± 12.41 | 75.99 ± 11.00 | 98.56 ± 1.41 | |
9 | 125.63 ± 20.31 | 75.28 ± 9.61 | 92.06 ± 13.17 | 74.67 ± 12.18 | 98.68 ± 1.51 | |
10 | 129.94 ± 12.47 | 80.67 ± 8.09 | 97.09 ± 9.55 | 73.51 ± 19.52 | 98.57 ± 1.43 | |
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43.37 | 54.53 | 51.21 | 8.62 | 25302.70 | |
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0.000 | 0.000 | 0.000 | 0.000 | 0.000 | |
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MS group | 185.89 | 95.42 | 126.46 | 146.44 | 1.75 |
Indicator changes in patients of group B. (a) Blood pressure changes after implantation of bone cement, (b) changes of SPO2 after implantation, and (c) changes of heart rate after implantation.
In all patients of group A, SBP, DBP, MAP, HR, and SPO2 did not change significantly at each time point before or after bone cement implantation (
The change of hemodynamics after implantation of bone cement in group A (
SBP (mmHg) | DBP (mmHg) | MAP (mmHg) | HR (BPM) | SPO2 (%) | ||
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Before using bone cement | 128.36 ± 8.94 | 82.36 ± 9.72 | 97.69 ± 9.98 | 73.00 ± 8.91 | 99.50 ± 1.21 | |
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After using bone cement (min) | 1 | 126.36 ± 10.84 | 82.18 ± 9.59 | 96.90 ± 10.74 | 73.82 ± 11.91 | 98.18 ± 1.40 |
2 | 122.45 ± 14.94 | 78.18 ± 10.84 | 92.94 ± 12.21 | 73.55 ± 12.96 | 97.18 ± 1.40 | |
3 | 124.18 ± 8.66 | 75.55 ± 9.81 | 91.76 ± 10.19 | 75.36 ± 10.42 | 95.55 ± 1.29 | |
4 | 121.73 ± 8.63 | 74.55 ± 8.91 | 90.28 ± 9.19 | 77.55 ± 10.93 | 95.90 ± 1.07 | |
5 | 120.82 ± 8.84 | 74.45 ± 10.01 | 89.91 ± 11.21 | 78.45 ± 10.61 | 95.27 ± 1.27 | |
6 | 121.25 ± 8.03 | 73.25 ± 10.29 | 89.25 ± 11.04 | 80.88 ± 11.03 | 96.15 ± 1.46 | |
7 | 122.25 ± 9.47 | 75.25 ± 10.55 | 90.92 ± 10.91 | 77.68 ± 10.13 | 96.86 ± 3.72 | |
8 | 124.14 ± 4.95 | 76.71 ± 10.77 | 92.52 ± 12.71 | 75.00 ± 11.90 | 98.14 ± 1.57 | |
9 | 124.57 ± 9.03 | 77.29 ± 10.61 | 93.05 ± 11.14 | 72.85 ± 12.81 | 98.38 ± 1.59 | |
10 | 126.00 ± 11.31 | 80.67 ± 10.07 | 95.78 ± 10.48 | 73.00 ± 9.47 | 98.67 ± 0.59 | |
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3.87 | 6.33 | 4.37 | 3.81 | 45.28 | |
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0.000 | 0.000 | 0.000 | 0.000 | 0.000 | |
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MS group | 94.22 | 102.45 | 119.49 | 122.68 | 2.83 |
Indicator changes in patients of group A. (a) Changes of blood pressure after implantation of bone cement, (b) changes of SPO2 after implantation, and (c) the change of heart rate after implantation.
Currently, the application of bone cement prosthesis to elderly patients with femoral neck fracture is quite popular. However, there are still many clinical issues in bone cement materials and technology [
In the present study, the patients without treatment of epinephrine hydrochloride displayed blood pressure decrease in varying degrees after bone cement implantation. SPO2 decreased significantly, indicating that the bone cement implantation had a significant influence on haemodynamics. It could be attributed to multiple factors. In in vitro experiments performed by Kim et al. [
In our study, we also found that, in patients without treatment of epinephrine hydrochloride, blood pressure decreasing (5–45 mmHg) was most obvious 2~6 min after bone cement implantation, SPO2 decreased significantly, and HR increased slightly. Maybe it was due to the toxic effects of bone cement monomer, which led to the formation of tiny blood clots and caused a mild pulmonary embolism. Thus, it resulted in peripheral blood pressure decrease and the compensatory increase of the heart rate in order to increase cardiac output. Moreover, the bone cement could directly inhibit myocardium, with the decreased myocardial contractility or the abnormalities of conduction system. It may result in decreased cardiac output or arrhythmia, which further exacerbates the decrease of blood pressure. Memtsoudis et al. [
Modern bone cement technique obtains the maximum degree of bone cement interlocking effect through the use of low-viscosity bone cement and compression techniques. However, the application of this technology could produce great intramedullary pressure in the femoral bone marrow cavity. This pressure exceeds the pressure in the general venous circulation, causing the rupture of intramedullary blood vessel with thin wall. Rupture of blood vessels could make the intramedullary fat. Moreover, it may lead to bone marrow, bone debris, and bone cement particles entering into blood vessels and bloodstream and through the metaphyseal veins. Embolism or air embolism is formed due to heat expansion of gases into the blood circulation system [
In the present study, there were 3 cases of blood pressure decrease and 1 case of arrhythmia in group A. We speculated that the 4 patients had mild bone cement pulmonary embolism. In group A, the medullary cavity was flushed with saline epinephrine hydrochloride and packed with the gauze dipped with saline epinephrine hydrochloride. Firstly, epinephrine can constrict blood vessels to maintain the blood vessel tension, increase the serum sodium level, and enhance myocardial tension to restore the effective circulating blood volume and increase the blood pressure. Secondly, epinephrine can reduce the absorption reaction of the bone cement monomer against the toxic effects of bone cement monomer through constricting blood vessels. Thirdly, epinephrine can constrict the small blood vessels in the bone marrow cavity, which reduces the chance of the air, fat, bone marrow, blood clots, and bone cement particles entering into the blood circulation system. Thus, it greatly reduces the incidence of pulmonary embolism caused by bone cement. Therefore, flushing the bone marrow cavity with saline epinephrine hydrochloride and packing the bone marrow cavity with the gauze dipped with the saline epinephrine hydrochloride could reduce the incidence of bone cement pulmonary embolism.
In summary, bone cement implantation has significant influence on hemodynamics in elderly patients with hemiarthroplasty. Flushing the bone marrow cavity with saline epinephrine hydrochloride is an effective measure to reduce the incidence of bone cement pulmonary embolism.
The authors declare that there is no conflict of interests regarding the publication of this paper.
The authors would like to express their gratitude to Le Kang and Linchao Sang from Hebei Medical University for their contributions in collecting the patient data. The authors thank Xiaohui Zhang from Beijing International Studies University.