Table 2.

Intraoperative surgical and anaesthetic roles to reduce the risk of BCIS. Reproduced from the Association of Anaesthetists/BOA/BGS guideline.²⁰

Conduct of surgery	Ask the anaesthetist to confirm that he/she has heard your instruction to the theatre team that you are about to prepare the femoral canal for cement and prosthesis insertion.
	Carefully prepare, wash, and dry the femoral canal. Use of a pressurised lavage system is recommended to clean the endosteal bone of fat and marrow contents.
	Use a distal suction catheter on top of an intramedullary plug. Insert the cement from a gun in retrograde fashion on top of the plug and pull the catheter out as soon as it is blocked with cement.
	Do not use excessive manual pressurisation or pressurisation devices in patients at higher risk of cardiovascular events.
Conduct of anaesthesia	Ensure that the patient is adequately hydrated before induction of and during anaesthesia.
	Maintain vigilance for possible cardiovascular events once the femoral head is removed and the surgeon has verbally indicated his/her intent to instrument the femoral canal.
	Confirm to the surgeon that you are aware of preparation of the femoral canal for cement and prosthesis insertion.
	Aim to maintain the systolic blood pressure within 20% of preinduction values throughout surgery, using vasopressors and/or fluids. Invasive blood pressure monitoring is indicated for patients at higher risk.
	Be ready to give vasopressors, e.g. metaraminol/adrenaline in case of cardiovascular collapse.