Histamine release and cardiovascular reactions to implantation of bone cement during total hip replacement]

Cardiovascular reactions to acrylic bone cement in patients with total hip replacement are a common complication. Hypotension and arrhythmias are the most frequently observed symptoms. Elderly patients with fractures of the femoral neck constitute a special risk group. In some patients these reactions can be fatal. The mechanisms suggested to explain these reactions are embolism of air, polymer or fat, reaction to the heat, and toxic or vasodilating effects of the acrylic monomer. In a pilot study and in a case report a significant rise of the plasma histamine was described following cementation of the femur. We therefore performed an investigation to find whether application of bone cement to the femur caused histamine release in elective hip surgery, and, independently of this, also investigated whether premedication with H1- + H2-antagonists had any effect on the cardiovascular reactions due to bone cement implantation into the femoral shaft in elderly patients with hip fracture. METHODS. Part I. In all, 40 patients, scheduled for elective surgical hip replacement were anesthetized by general or epidural anesthesia. Patients were continuously monitored by ECG. Blood pressure was recorded noninvasively at 2-min intervals during the study. Blood samples for the determination of the plasma histamine were taken immediately before implantation of the bone cement into the femur, and 2, 5, and 10 min after. Part II. A further group of 20 patients aged greater than or equal to 70 years with fractures of the femoral neck and in whom total hip replacement was planned were included in the study. In this group, 10 patients were randomly assigned to receive 4 mg clemastine + 400 mg cimetidine i.v. about 15 min before implantation of the bone cement. All patients were operated on under general anesthesia. ECG was monitored continuously and blood pressure was monitored at 2-min intervals during the study. Changes of the blood pressure and heart rate and therapeutic interventions following the implantation of the bone cement were documented. RESULTS. Part I. In 11 of the 40 patients (27.5%) plasma histamine increased by greater than 0.5 ng/ml (9 patients greater than 1 ng/ml). In comparable groups (patients with a control systolic blood pressure less than or equal to 130 mmHg) the histamine responders showed a significantly greater reduction in systolic blood pressure (-5.7 +/- 14.7 vs -17.7 +/- 8.6 mmHg). Part II. In the control group we observed a significantly greater fall in systolic blood pressure than in premedicated patients (41.5 +/- 25.4 vs 11.0 +/- 13.4 mmHg). In the control group 7 of the 10 patients required therapeutic interventions, while in the premedicated group only one therapeutic intervention was necessary (P less than 0.05). DISCUSSION. We have demonstrated that the implantation of acrylic bone cement into the femur may increase plasma histamine by greater than 1 ng/ml. In elderly patients with preexisting cardiac diseases or/and hypovolemia even moderate histamine release can cause serious, sometimes potentially fatal, cardiovascular complications. In this special risk group with hip fractures we found a significant reduction in the frequency of cardiovascular reactions to bone cement implantation in patients premedicated with H1 + H2 antagonists. Because we also observed significant falls in systolic blood pressure in premedicated patients, we assume that the pathogenesis of cardiovascular reactions to bone cement implantation is multifactorial. It may be that potentially lethal complications only occur if two or more of the predisposing factors (hypovolemia, myocardial insufficiency, arrhythmia, embolism, histamine release) are present simultaneously. Pre- and intraoperative measures therefore have to be instituted to eliminate all possible risk factors.