An 80 year-old Female with a past medical history of left femoral neck fracture s/p hemiarthroplasty one year ago presented to our institution with a 4 month history of purulent drainage from her left hip wound. The patient was scheduled for an incision and drainage with placement of antibiotic cement spacer. Preoperative workup showed a history of hypertension, Type 2 Diabetes, CHF with ejection fraction of 30%, and severe pulmonary hypertension with RVSP 75mmHg. Physical examination was within normal limits except for a painfully infected left hip with poor range of motion and strengths in the left leg.
In the operating room, awake arterial line access was obtained and a gentle induction of general anesthesia with an endotracheal tube was achieved. The patient was then placed in lateral decubitus position. Due to the patient’s history of CHF, severe pulmonary hypertension, and high risk of cardiovascular decompensation from cement embolism, transesophageal echocardiography (TEE) was used to monitor cardiac function throughout the case. Dobutamine and vasopressin drips were started shortly after the incision due to 300cc of blood loss, despite cc for cc replacement with 5% albumin. During the antibiotic cementing process, large amounts of debris was noticed on the TEE in the RV inflow-outflow tract view. Soon after, the patient went into PEA arrest. 1mg of epinephrine was given and 2 provider lateral chest compressions was performed. Return of spontaneous circulation was achieved within less than 1 minute of CPR. The case was successfully completed and the patient was extubated in the operating room, as arterial blood gas and hemodynamics were within acceptable limits. Patient was discharged from the hospital without further complications on POD#6.
Methylmethacrylate bone cement embolism is a well-documented phenomenon that can occur during various orthopedic procedures. Hip arthroplasty procedures are of particular high risk for embolization. We describe a case where bone cement embolism was visualized with TEE. TEE is not routinely employed during orthopedic procedures requiring bone cementing. However, in our case, TEE allowed for rapid diagnosis of cement embolism in addition to continuous cardiac function monitoring. We speculate that cement embolization occurs fairly commonly during orthopedic procedures involving bone cement. Most cases of cement embolization are likely subclinical, but high risk patients with multiple cardiopulmonary comorbidities are more likely to have negative clinical manifestations. More investigational studies involving TEE and bone cement procedures would be needed in order to confirm our hypothesis.
