Download PDF
Vet Comp Orthop Traumatol 1998; 11(02): 68-75
DOI: 10.1055/s-0038-1632613
Original Research
Schattauer GmbH

Detection of Embolic Events by Capnography and Trans-oesophageal Echocardiography during Total Hip Replacement

S. Reindl
1   From the Department of Surgery, Veterinary Faculty of the Ludwig-Maximilians-University of Munich, Germany
,
U. Matis
1   From the Department of Surgery, Veterinary Faculty of the Ludwig-Maximilians-University of Munich, Germany
› Author Affiliations
Further Information

Publication History

Received 07 April 1996

Accepted 26 November 1997

Publication Date:
10 February 2018 (online)

Also available at
    Permissions and Reprints

Summary

Trans-oesophageal echocardiography and continuous monitoring of the partial pressure of carbon dioxide at end expiration (PETCO2) were performed in 63 dogs during total hip replacement and in three dogs during femoral stem revision. The PET CO2 usually did not change during insertion of the acetabular prosthesis, but in 17.5% of the cases, it decreased by more than 10 mmHg after insertion of the femoral prosthesis. In all of the cases, transoesophageal echocardiography revealed echogenic structures in the right side of the heart, immediately after insertion of the acetabular and of the femoral prostheses. These appeared as either numerous pinpoint echoes, which passed through the right side of the heart in a “snow flurry” like fashion, or more echogenic particles. The embolaemia, seen ultrasonographically, was categorized into one of six grades of severity. Statistical analysis showed significant positive correlations between the severity of the embolaemia and the extent of the decrease in PETCO2 (rs = 0.405; P = 0.001; n = 60), and between the severity of the embolaemia and the duration of the decrease in PETCO2 before it returned to baseline values (rs = 0.345; P = 0.007; n = 60).

Trans-oesophageal echocardiography demonstrated that embolaemia was induced during cemented prosthesis insertion. It was proposed that an increase in intramedullary pressure, during insertion, forces bone marrow into the venous circulation. Bone marrow itself can constitute an embolus, but also it may activate intravascular coagulation, thus leading to thromboembolism, in addition to bone marrow embolism. Elongated particulate emboli, up to several centimetres in length, were seen on ultrasonogrammes and were thought to be, at least in part, products of intravascular coagulation. A significant decrease in the platelet concentration in peripheral venous blood, after insertion of the femoral prosthesis, was also indicative of intravascular coagulation. The extent of the impairment of gas exchange was documented by means of capnography. The significant positive correlation between the embolaemia, seen via ultrasonography, and the decrease in PETCO2 strongly suggest a causal relationship between the two variables. The rapid recovery, that occurred in most patients, is attributed to the enormous lytic ability of pulmonary tissue. Prophylactic measures include the maintenance of normovolaemia during the operations, thorough lavage of the intramedullary cavity before prosthesis insertion and steps to prevent an increase in intramedullary pressure during implantation.

Using trans-oesophageal echocardiography, embolaemia in the right side of the heart was consistently detected immediately after insertion of cemented acetabular as well as cemented femoral prostheses in dogs. There was a significant correlation between the severity of the embolaemia and the decrease in carbon dioxide at end expiration (PETCO2) after femoral prosthesis insertion.

Keywords

Total hip replacement - trans-oesophageal echocardiography - capnometry - embolism-fat - embolism-bone marrow
 

  • REFERENCES

  • 1 Matis U.. Total hip replacement: State of the art in Europe. 3rd Annual Veterinary Surgical Forum of the American College of Veterinary Surgeons, München, 26. 5 1989
    PubMedGoogle Scholar
  • 2 Ereth MH, Weber JG, Abel MD. et al Cemented versus noncemented total hip and intrapulmonary hunting. Mayo Clin Proc 1992; 67: 1066-74.
    CrossrefPubMedGoogle Scholar
  • 3 Hohn RB, Olmstead ML, Turner TM. et al Der Hüftgelenkersatz beim Hund. Tierärztl Prax 1986; 14: 377-88.
    PubMedGoogle Scholar
  • 4 Souquet J, Hanrath P, Zitelli L. et al Transesophageal phased array for imaging the heart. IEEE Trans Biomed Engn 1982; 29: 707-12.
    PubMedGoogle Scholar
  • 5 Thier W, Schlüter M, Kremer P. et al Transösophageal zweidimensionale Echokardiographie: bessere Darstellung intraatrialer Strukturen. Dtsch Med Wschr 1983; 108: 1903-7.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Heinrich H, Kremer P, Winter H. et al Transoesophageale zweidimensionale Echokardiographie bei Hüftendoprothesen. Anaesthesist 1985; 34: 118-23.
    PubMedGoogle Scholar
  • 7 Bednarz F, Roewer N. Intraoperativer Nachweis von Luftembolien und korpuskulären Embolien mit Hilfe der Pulsoximetrie und Kapnometrie. Vergleichende Untersuchungen mit der transösophagealen Echokardiographie. Anästh Intensivther Notfallmed 1989; 24: 20-6.
    PubMedGoogle Scholar
  • 8 Heinrich H, Kremer P, Winter H. et al Wilder-Smith O.. Embolic events during total hip replacement. An echocardiographic study. Acta Orthop Belg 1988; 54: 12-7.
    PubMedGoogle Scholar
  • 9 Kremer P, Aschenberg W, Schröder E. et al Embolism during hip surgery: A transesophageal echocardiographic study. European Heart J 1985; (Suppl. 06) Suppl. 125.
    PubMedGoogle Scholar
  • 10 Roewer N, Beck H, Kochs E. et al Detection of venous embolism during intraoperative monitoring by two-dimensional transesophageal echocardiography. Anesthesiology 1985; 63: A169.
    CrossrefPubMedGoogle Scholar
  • 11 Menne E.. Transösophageal-echocardiographische, hamostasiologische und mikroskopisch- morphologische Untersuchungen zur Pathogenese von intraoperativen Embolien bei Hüftgelenksersatz. Inaugural Dissertation, Technische Universität München 1991
    PubMedGoogle Scholar
  • 12 Rodrigo JL, Alfonso F, Aubele A. et al Transesophageal echocardiographic right atrial findings during prosthetic hip replacement. Amer J Cardiol 1994; 73: 823-4.
    CrossrefPubMedGoogle Scholar
  • 13 Lenz G, Klöss T, Schorer R. Grundlagen und Anwendung der Kapnometrie. Anasth Intensivmed 1985; 26: 133-41.
    PubMedGoogle Scholar
  • 14 Homsy ChA. Tullos HS. King JW.. Physiological sequel from implantation of rapidcure acrylic compounds. J Bone Jt Surg; 51A 805.
    PubMedGoogle Scholar
  • 15 Schlag G.. Experimentelle und klinische Untersuchungen mit Knochenzementen. Wien: Brüder Hollinek 1974
    PubMedGoogle Scholar
  • 16 Drinker H, Goel VK, Panjabi MM. Acute in vivo toxicity of methylmethacrylate pressurization in the dog femur. Trans Orthop Res Soc 1981; 6: 131.
    PubMedGoogle Scholar
  • 17 Sherman RMP, Byrick RJ, Kay JC. et al The role of lavage in preventing hemodynamic and blood-gas changes during cemented arthroplasty. J Bone Jt Surg 1983; 65 A 500-6.
    CrossrefPubMedGoogle Scholar
  • 18 Burke DW, Gates EI, Harris WH. Centrifugation as a method of improving tensile and fatigue properties of acrylic bone cement. J Bone Jt Surg 1984; 66 A 1265-73.
    CrossrefPubMedGoogle Scholar
  • 19 Sherman RMP, Waddel JP, Kay JC. et al Large airway response to cemented arthroplasty: Relationship to hypoxaemia. An experimental study in dogs. Acta Anaesth Scand 1984; 28: 426-31.
    CrossrefPubMedGoogle Scholar
  • 20 Byrick RJ, Kay JC, Mullen JBM. Pulmonary marrow embolism: a dog model simulating dual component cemented arthroplasty. Can J Anaesth 1987; 34: 336-42.
    CrossrefPubMedGoogle Scholar
  • 21 Hofmann AA, Wyatt RWB, Gilbertson AA. et al The effect of air embolization from the femoral canal on hemodynamic parameters during hip arthroplasty. Clin Orthop Rel Res 1987; 218: 290-6.
    PubMedGoogle Scholar
  • 22 Orsini EC, Byrick RJ, Mullen JBM. et al Cardiopulmonary function and pulmonary microemboli during arthroplasty using cemented or non-cemented components. J Bone Jt Surg 1987; 69 A 822-32.
    CrossrefPubMedGoogle Scholar
  • 23 Wenda K, Grieben A, Rudigier J. et al Pharmakologische Effekte und Kinetik von Methylmethacrylat-Monomer. Aktuel Probl Chir Orthop 1987; 31: 83-6.
    PubMedGoogle Scholar
  • 24 Byrick RJ, Mullen JBM, Kay JC. et al Prevention of fat and marrow microembolism during cemented arthroplasty. Trans Orthop Res Soc 1988; 13: 550.
    PubMedGoogle Scholar
  • 25 Byrick RJ, Bell RS, Kay JC. et al High-volume, high-pressure pulsatile lavage during cemented arthroplasty. J Bone Jt Surg 1989; 71 A 1331-6.
    CrossrefPubMedGoogle Scholar
  • 26 Byrick RJ, Kay JC, Mullen JB. Capnography is not as sensitive as pulmonary artery pressure monitoring in detecting marrow microembolism. Anesth Analg 1989; 68: 94-100.
    CrossrefPubMedGoogle Scholar
  • 27 Doran RJ, Wong PY, Mullen BJ. et al Haemodynamic and prostanoid response to fat and microembolism after cemented arthroplasty. Can J Anaesth 1989; 36: S66-8.
    PubMedGoogle Scholar
  • 28 Byrick RJ, Mullen JB, Wong PY. et al Prostanoid production and pulmonary hypertension after fat embolism are not modified by methylprednisolone. Can J Anaesth 1991; 38: 660-7.
    CrossrefPubMedGoogle Scholar
  • 29 Otto K, Matis U.. Cardiopulmonary changes during anesthesia for total hip replacement in dogs. XVI. Congress of the World Small Animal Veterinary Association (WSAVA), Wien, Österreich 1991
    PubMedGoogle Scholar
  • 30 Otto K, Matis U. Changes in cardiopulmonary variables and platelet count during anesthesia for total hip replacement in dogs. Vet Surg 1994; 23: 266-73.
    CrossrefPubMedGoogle Scholar
  • 31 Byrick RJ, Wong PY, Mullen JB. et al Ibuprofen pretreatment does not prevent hemodynamic instability after cemented arthroplasty in dogs. Anesth Analg 1992; 75: 515-22.
    PubMedGoogle Scholar
  • 32 Wheelwright EF, Byrick RJ, Wigglesworth DF. et al Hypotension during cemented arthroplasty. Relationship to cardiac output and fat embolism. J Bone Jt Surg 1993; 75 B 715-23.
    PubMedGoogle Scholar
  • 33 Reindl S.. Nachweis venöser Embolien mittels transösophagealer Echokardiographie bei Implantation von Hüfttotalendoprothesen mit Polymethylmethacrylat beim Hund. Inaugural Dissertation. Universität München 1995
    PubMedGoogle Scholar
  • 34 Ohnsorge P, Ohnsorge J. Änderungen des Oberschenkelmarkraumdruckes beim Einzementieren von Hüftendoprothesen - Experimentelle Untersuchungen. Med Orthop Techn 1974; 1: 9-13.
    PubMedGoogle Scholar
  • 35 Ohnsorge P.. Experimentelle Untersuchungen zur Bestimmung des intramedullären Druckverlaufes im Femur beim Eindrücken von Knochenzement und beim Einbringen einer Femurschaftendoprothese. Inaugural Dissertation, Universität Köln 1971
    PubMedGoogle Scholar
  • 36 Breed AL. Experimental production of vascular hypotension, and bone marrow and fat embolism with methylmethacrylate cement. Traumatic hypertension of bone. Clin Orthop Rel Res 1974; 102: 227-44.
    CrossrefPubMedGoogle Scholar
  • 37 Herndon JH, Bechtol ChO, Crickenberger DP. Fat embolism during total hip replacement. A prospective study. J Bone Jt Surg 1974; 56 A 1350-62.
    CrossrefPubMedGoogle Scholar
  • 38 Modig J, Busch C, Olerud S. et al Arterial hypotension and hypoxaemia during total hip replacement. The Importance of thromboplastic products, fat embolism and acrylic monomers. Acta anaesth scand 1975; 19: 28-43.
    CrossrefPubMedGoogle Scholar
  • 39 Schlag G. Mechanisms of cardiopulmonary disturbances during total hip replacement. Acta Orthop Belg 1988; 54: 6-11.
    PubMedGoogle Scholar
  • 40 Schöndorf TH, Hey D. Gerinnungsanalytische Untersuchungen zur Thrombogenese bei großen Hüftgelenksoperationen. Inn Med 1976; 3: 365-70.
    PubMedGoogle Scholar
  • 41 Giercksky K-E, Bjorklid E, Prydz H. et al Circulating tissue thromboplastin during hip surgery. Eur Surg Res 1979; 11: 296-300.
    CrossrefPubMedGoogle Scholar
  • 42 Ketterl R, Haas S, Fritsche H-M. et al. Veränderungen der Thrombozytenmorphologie und der Thrombozytenfunktion im Verlauf von Hüft-Totalendoprothesenoperationen. Med Welt 1980; 31: 743-7.
    PubMedGoogle Scholar
  • 43 Sikorski JM, Bradfield JW. Fat and thromboembolism after total hip replacement. Acta Orthop Scand 1983; 54: 403-7.
    CrossrefPubMedGoogle Scholar
  • 44 Matis U.. Experimentelle Untersuchungen zur intraoperativen Hämostase unter besonderer Berücksichtigung der Thrombozytenmorphologie und -funktion. Habilitationsschrift, Universität München 1980
    PubMedGoogle Scholar
  • 45 Bras JM, Veraart BE. Pulmonary bone embolism after total hip replacement. J Bone Jt Surg 1980; 62 B 22-4.
    PubMedGoogle Scholar
  • 46 Nolan JP. Arterial oxygenation and mean arterial blood pressure in patients undergoing total hip replacement: cemented versus uncemented components. Anaesthesia 1994; 49: 293-9.
    CrossrefPubMedGoogle Scholar
  • 47 Park WY, Balingt P, Kenmore PI. et al Changes in arterial oxygen tension during total hip replacement. Anesthesiology 1973; 39: 642-4.
    CrossrefPubMedGoogle Scholar
  • 48 Vermaut G, Mortelmans Y, Mulier J. et al Prevention and treatment of cardiopulmonary reactions during total hip replacement. Acta Orthop Belg 1988; 54: 18-20.
    PubMedGoogle Scholar
  • 49 Kallos T. Impaired arterial oxygenation associated with use of bone cement in the femoral shaft. Anesthesiology 1975; 42: 210-6.
    CrossrefPubMedGoogle Scholar
  • 50 Fowler AW. Methylmethacrylic cement and fat embolism. British Med J 1972; 4: 108.
    PubMedGoogle Scholar
  • 51 Byrick RJ, Waddell JP, Wheelwright EF. Hypotension during cemented arthroplasty. J Bone Jt Surg 1994; 76 B 337.
    PubMedGoogle Scholar
  • 52 Issendorff von W-D, Ritter G. Untersuchungen zur Höhe und Bedeutung des intramedullären Druckes während des Einzementierens von Hüftendoprothesen. Unfallchirurg 1977; 3: 99-104.
    PubMedGoogle Scholar
  • 53 Alexander JB. Barron DW. Biochemical disturbances associated with total hip replacement. J Bone Jt Surg 1979; 61 B 101-6.
    PubMedGoogle Scholar
  • 54 Kallos T, Enis JE, Gollan F. et al Intramedullary pressure and pulmonary embolism of femoral medullary contents in dogs during insertion of bone cement and a prosthesis. J Bone Jt Surg 1974; 56 A 1363-7.
    CrossrefPubMedGoogle Scholar
  • 55 Draenert K.. Forschung und Fortbildung in der Chirurgie des Bewegungsapparates 2. Zur Praxis der Zementverankerung. München: Art and Science 1988
    PubMedGoogle Scholar
  • 56 Svartling N. Detection of embolized material in the right atrium during cementation in hip arthroplasty. Acta Anaesthesiol Scand 1988; 32: 203-8.
    CrossrefPubMedGoogle Scholar