Bone cement implantation syndrome in patients with cemented endoprostheses for metastatic bone disease in the femur

Background
Patients with bone metastases in the femur (BMf) may experience pathological fractures requiring surgery with cemented endoprostheses (EPR). At cementation and prosthesis insertion, patients are at risk of experiencing hypoxia, hypotension, cardiac failure and potentially death, known as bone cement implantation syndrome (BCIS). We aimed to 1) investigate the incidence and grade of BCIS in patients with BMf treated with cemented EPR, and 2) examine if the incidence or extent of BCIS has decreased after a change of a combined anesthesiologic and surgical protocol.
Methods
We retrospectively assessed patients with BMf operated with cemented EPR in two periods 2017 – 2018 (early cohort) and 2019 – 2020 (late cohort) and stratified before and after the intervention.
Results
Comparing the early and late cohorts, 26/86 (32 %) vs. 30/80 (35 %) experienced BCIS, but mild BCIS (grade 0 + 1) was seen in 79 % vs. 86 %, and severe BCIS (grade 2 + 3) in 21 % vs. 14 %. In the late cohort the per-operative use of vasopressors was higher (86 % vs. 59 %, p < 0.001), we found fewer pulmonary embolisms (PE) (p = 0.024), and a trend toward a reduced length of stay (LOS). 30-day survival was lower for patients with grade 0 + 1 compared to grade 2 + 3 (p = 0.03).
Conclusions
BCIS occurs in more than 1/3 of patients operated for BMf with cemented EPR. An increased multidisciplinary focus on BCIS may reduce the complications of BCIS, such as PE and LOS.