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Anesth Analg 2003;97:293-294
© 2003 International Anesthesia Research Society

LETTERS TO THE EDITOR

Fat and Bone Marrow Embolism During Percutaneous Vertebroplasty

Matthias J. Koessler, MD, Nikolaus Aebli, MD, and Rocco P. Pitto, MD PhD

Department of Anesthesiology and Intensive Care, Waldkrankenhaus St. Marien, Erlangen, Germany Department of Orthopaedic Surgery,, Dunedin School of Medicine, Dunedin Hospital, Dunedin, New Zealand Department of Orthopaedic Surgery,, University of Auckland, Middlemore Hospital, Auckland, New Zealand

To the Editor:

Chen et al. (1) report a case of pulmonary embolism leading to cardiac arrest during percutaneous vertebroplasty. Increased intraosseous pressure during insertion of cement is the causative factor for the passage of fat and bone marrow into the venous circulation and the right heart. Embolic material can be visualized using transesophageal echocardiography (TEE) (2–4).

In a sheep model (2) TEE revealed during vertebroplasty embolic material in the right atrium and the pulmonary artery. Online data registration showed within 2 ± 1 s after injection of bone cement a decrease of heart rate, mean arterial pressure, and an increase of pulmonary artery pressure. Whereas first echogenic particles were visible with TEE 6 ± 1 s after cement injection. A second, less severe, hemodynamic affection started after 18 ± 2 s. The first (immediate) reaction could be mediated by a reflex activity, increasing the pulmonary vascular tone. This is supported by a study of Jahn et al. (5), who found that a thoracic sympathetic blockade can improve the cardiovascular outcome after pulmonary embolism. The second (late) reaction is caused by occlusion of pulmonary vessels by fat and bone marrow, leading to reduced left ventricular filling and low output.

Vertebroplasty can cause pulmonary embolism of fat and bone marrow and a cardiac reflex response. A bone-venting hole connected to a vacuum suction (3,4) and epidural injection of local anesthetics may reduce the risk of cardiopulmonary complications.

References

  1. Chen H-L, Wong C-S, Ho S-T, et al. A lethal pulmonary embolism during percutaneous vertebroplasty. Anesth Analg 2002; 95: 1060–2.[Abstract/Free Full Text]
  2. Aebli N, Krebs J, Davis G, et al. Fat embolism and acute hypotension during vertebroplasty: an experimental study in sheep. Spine 2002; 27: 460–6.[ISI][Medline]
  3. Koessler MJ, Fabiani R, Hamer H, Pitto RP. The clinical relevance of embolic events detected by transesophageal echocardiography during cemented total hip arthroplasty: a randomized clinical trial. Anesth Analg 2001; 92: 49–55.[Abstract/Free Full Text]
  4. Pitto RP, Koessler M, Draenert K. The John Charneley Award: Prophylaxis of fat and bone marrow embolism during cemented total hip arthroplasty. Clin Orthop 1998; 355: 23–34.
  5. Jahn UR, Waurick R, Van Aken H, et al. Thoracic, but not lumbar, epidural anesthesia improves cardiopulmonary function in ovine pulmonary embolism. Anesth Analg 2001; 93: 1460–5.[Abstract/Free Full Text]
 

Response

Hsueh-Lin Chen, MD, Ching-Tang Wu, MD, and Chih-Shung Wong, PhD MD

Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan

In Response:

We thank Koessler et al. for their interesting, concerned. and valuable comments on our article (1). Their experimental animal study demonstrated that embolic material in the right atrium and the pulmonary artery is always observed during vertebroplasty (2).

We completely agree with their comments that thoracic epidural sympathetic blockade can improve the cardiovascular outcome (3), and that a bone venting connected to a vacuum suction may reduce the risk of cardiovascular complications (4,5). Moreover, perhaps the experience of the surgeon plays the most important role in this complication. In this case, multiple vertebral punctures and injections of several batches of cement were performed by an inexperienced surgeon; this was his third procedure. Our experience is that these procedures were smooth and without any complication during operation under either IV sedation or general anesthesia. However, we suggest that intraoperative TEE is the paramount monitor for the patient receiving general anesthesia, and a thoracic epidural anesthesia may be a good anesthetic choice for high-risk patients.

References

  1. Chen H-L, Wong C-S, Ho S-T, et al. A lethal pulmonary embolism during percutaneous vertebroplasty. Anesth Analg 2002; 95: 1060–2.
  2. Aebli N, Krebs J, Davis G, et al. Fat embolism and acute hypotension during vertebroplasty: an experimental study in sheep. Spine 2002; 27: 460–6.
  3. Jahn UR, Waurick R, Van Aken H, et al. Thoracic, but not lumbar, epidural anesthesia improves cardiopulmonary function in ovine pulmonary embolism. Anesth Analg 2001; 93: 1460–5.
  4. Koessler MJ, Fabiani R, Hamer H, Pitto RP. The clinical relevance of embolic events detected by transesophageal echocardiography during cemented total hip arthroplasty; a randomized clinical trial. Anesth Analg 2001; 92: 49–55.
  5. Pitto RP, Koessler M, Draenert K. The John Charneley Award: Prophylaxis of fat and bone marrow embolism during cemented total hip arthroplasty. Clin Orthop 1998; 355: 23–34.




This Article
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Right arrow Articles by Koessler, M. J.
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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press