Hemodynamic Effects of Bone Cement During Hip Arthroplasty Under Neuraxial Anesthesia

Perioperative hemodynamic monitoring is a cornerstone of anesthetic management, enabling the assessment of cardiovascular function and optimization of organ perfusion. Hip arthroplasty is frequently performed in elderly patients and is associated with a risk of significant hemodynamic instability, particularly during bone cement implantation. Bone Cement Implantation Syndrome is characterized by hypotension, hypoxia, and cardiovascular collapse, which may result in postoperative organ dysfunction.

In this prospective observational study, patients undergoing hip arthroplasty under neuraxial anesthesia are evaluated to characterize perioperative hemodynamic changes using continuous arterial waveform analysis. A pressure recording analytical method is used to measure cardiac output and related hemodynamic parameters through invasive arterial blood pressure monitoring.

Patients aged 50 to 90 years with ASA physical status I-III scheduled for elective or fracture-related hip arthroplasty are included. Eligible patients are divided into two groups according to surgical technique: cemented and non-cemented hip arthroplasty. No intervention or randomization is performed; surgical and anesthetic management follow routine clinical practice.

Hemodynamic parameters are recorded at predefined time points, including baseline measurements, after neuraxial anesthesia, at surgical incision, before and after cement or prosthesis implantation, during the first hypotensive episode if present, and at the end of surgery. Fluid responsiveness is assessed using Trendelenburg maneuver-induced changes in cardiac output and stroke volume.

Arterial blood gas analysis is performed intraoperatively as clinically indicated and routinely at the end of surgery. Postoperative laboratory assessments include serum creatinine, NT-proBNP, and troponin I measured on postoperative day 0, followed by daily measurements on postoperative days 1, 2, and 3. Urine output is monitored during the postoperative period.

The primary objective of the study is to evaluate perioperative hemodynamic changes associated with bone cement implantation. Secondary objectives include assessing the relationship between intraoperative hemodynamic alterations and early postoperative cardiac and renal biomarkers. All collected data are analyzed statistically to determine differences between cemented and non-cemented procedures and to explore potential predictors of organ dysfunction.

Inclusion criteria

• Age between 50 and 90 years
• Scheduled for hip arthroplasty under neuraxial anesthesia
• ASA physical status I-III
• Body mass index (BMI) <30 kg/m²
• Planned invasive arterial blood pressure monitoring
• Expected surgical duration >2 hours
• Ability to provide written informed consent

Exclusion criteria

• Refusal to participate or inability to provide informed consent
• Planned surgery without invasive arterial blood pressure monitoring
• Mean arterial pressure <65 mmHg at initial monitoring
• Use of vasopressors or inotropes before anesthesia
• Fluid responsiveness detected by Trendelenburg maneuver
• Intraoperative blood loss exceeding tolerable limits
• Additional epidural drug administration during cement implantation
• Estimated glomerular filtration rate <30 mL/min/1.73 m²
• Ongoing renal replacement therapy
• Preoperative intensive care unit requirement
• NYHA class III-IV heart failure or left ventricular ejection fraction <40%
• Severe valvular heart disease
• Persistent cardiac arrhythmia
• Coagulation disorders
• Sensory block level below T8 after initial neuraxial anesthesia