Table 3 Three-stage process to reduce the incidence of problems in patients undergoing cemented hemiarthroplasty for proximal femoral fracture [17]

1. Identification of patients at high risk of cardiorespiratory compromise:

 a. Increasing age;

 b. Significant cardiopulmonary disease;

 c. Diuretics;

 d. Male sex.

2. Preparation of team(s) and identification of roles in case of severe reaction:

 a. Pre-operative multidisciplinary discussion when appropriate;

 b. Pre-list briefing and World Health Organization Safe Surgery checklist ‘time-out’.

3. Specific intra-operative roles:

 a. Surgeon:

  • Inform the anesthetist that you are about to insert cement;

  • Wash and dry the femoral canal;

  • Apply cement retrogradely using the cement gun with a suction catheter and intramedullary plug in the femoral shaft;

  • Avoid excessive pressurisation.

 b. Anesthetist:

  • Ensure adequate resuscitation pre- and intra-operatively;

  • Confirm to surgeon that you are aware that he/she is about to prepare/apply cement;

  • Maintain vigilance for signs of cardiorespiratory compromise. Use either an arterial line or non-invasive automated blood pressure monitoring set on the ‘stat’ mode during/shortly after application of cement;

  • Early warning of cardiovascular collapse may be heralded by a drop in systolic pressure. During general anesthetic, a sudden drop in end-tidal pCO₂ may indicate right heart failure and/or catastrophic reduction in cardiac output;

  • Aim for a systolic blood pressure within 20% of pre-induction value;

  • Prepare vasopressors in case of cardiovascular collapse.