Arterial Hypotension and Hypoxaemia During Total Hip Replacement: The Importance of Thromboplastic Products, Fat Embolism and Acrylic Monomers

Abstract

Thirteen patients submitted to total hip replacement surgery by the Charnley technique were studied. Operations were performed under epidural analgesia with the patients awake and breathing air. During the surgical procedure, the magnitude of tissue-thromboplastic activity, the amount of fat globules, the presence of bone marrow cells and the concentrations of acrylic monomers were determined in the pulmonary arterial blood. Simultaneously, arterial blood gases and blood pressure were monitored. Marked reductions of the arterial blood pressure and arterial oxygen tension occurred after impaction of the femoral prosthesis, and minor depressions appeared after insertion of the acetabular prosthesis. A significant correlation was found between the release of tissue-thromboplastic products into the pulmonary circulation, i.e., products that initiate intravascular coagulation and the circulatory and respiratory reactions. The pulmonary fat droplets, per se, seem to be of minor importance, and the release of acrylic monomers is probably of no importance for these reactions.

Influence of Bone Marrow Fat Embolism on Coagulation Activation in an Ovine Model of Vertebroplasty

“…An increase in thrombin-antithrombin complex concentration and changes in antithrombin and fibrinogen values were observed after reaming of the femoral medullary cavity for hip arthroplasty 24 and intramedullary nailing 28 , respectively. Modig et al 22 investigated the role of coagulation, fat embolism, and methylmethacrylate in the development of arterial hypotension and hypoxemia during total hip arthroplasty with cement. Activation of the coagulation cascade was observed immediately after the insertion of the femoral component.…”

“…More recently, coagulation activation during total hip arthroplasty with and without cement was demonstrated by an increase in thrombin-antithrombin complex and D-dimer values 23 . It has been suggested that coagulation may be activated by cell fragments released from the bone marrow cavity 22 or thromboplastin (protease, which converts prothrombin to thrombin) 22,29 . Thromboplastin may be released from adipose bone marrow tissue 29 or as a result of subendothelial tissue damage in the bone marrow cavity 28 or in the lungs 27 .…”

“…Activation of the coagulation cascade may have resulted in an additional embolic burden rendering the reduction of fat emboli ineffective. It has been suggested that the release of fat emboli and thromboplastin from the bone marrow cavity during hip arthroplasty may result in thrombogenesis [21][22][23] . Furthermore, polymethylmethacrylate may have inherent thrombogenic properties 24,25 .…”

Low risk of cardiac events during intramedullary instrumentation of lung cancer metastases

“…One reported complication of this procedure is pulmonary embolism manifested by hypotension, arrythmia, and oxygen desaturation (Kerr et al 1993, Choong 2003. In addition to the risk from fat emboli, air, tumor, bone marrow-thrombus aggregates, or other vasoactive inflammatory substances have also been implicated (Modig et al 1975, Christie et al 1995, Karachalios et al 2002. Barwood et al (2000) reported desaturation and hypotension in 11 of 45 patients treated by intramedullary nailing for fractures or impending fractures of the femur.…”

Air aspirated from the venous system during total hip replacement

“…The probe was connected to a Versatone R doppler model D 8 which was connected to a printer (Servograph Rea 310); a system that is efficient for the demonstration of air embolism.g When air is in the right atrium. the regular double sound of the Versatone doppler for each heart stroke changes into an irregular rattling sound and an associated irregular deflection at a frequency of [3][4][5] Hz and a duration of 101t300 ms and an amplitude of 1 SO./,, of that of the cardiac action (Fig. I).…”