- Discussion:
          - in some cases, application of pressurized cement is associated w/ an embolization phenomena (either cement elements or fat) which may
                  result in hypoxia, cardiac arrest, or death;
          - risk factors include older age and a patent foramen ovale (paradoxical embolization);
          - use of pulsatile lavage may help to prevent this embolization phenomena, by removing fat  and marrow from the canal;
          - in older co-morbid patients, consider avoiding pressurization of the cement within the canal, since the risk of acute embolization may be higher than late loosening;
    - removal of debris from femur:
         - may begin cement mixing while preparing bone bed for cement;
         - loose cancellous bone debris, blood, and tissue are removed w/ water pick &  brush are helpful, & routine mechanical drying of both acetabular &
                 femoral surfaces is important (continue water pick until returning fluid is clear);
         - apply dilute solution of Epi w/ moist sponge (prevents blood interposition)
         - references:
                 - Medullary lavage reduces embolic phenomena and cardiopulmonary changes during cemented hemiarthroplasty.
                 - An in vitro study of femoral intramedullary pressures during hip replacement using modern cement technique.
                 - High-volume, high-pressure pulsatile lavage during cemented arthroplasty.
    - optimize hemodynamics:
         - some surgeons will infuse one unit of autologous pRBC at this point to optimize preload and Hct;
         - consider increasing FiO2 during the cement application

  - references: 
       - Cement Venogram—A Risk of Satisfactory Cement Pressurization. 
       - Ten-year follow-up study of total hip replacement.
       - Is there a difference in perioperative mortality between cemented and uncemented implants in hip fracture surgery?
       - Periprosthetic fractures around hip hemiarthroplasty performed for hip fracture.
       - Reduction of severe cardiac complications during implantation of cemented total hip endoprostheses in femoral neck fractures
       - TEE and clinical features of fat embolism during cemented THA. A randomized study in patients with a femoral neck fracture.
       - Prophylaxis against fat and bone-marrow embolism during THA reduces the incidence of postoperative DVT: a controlled, RCT.
       - Cardiac output during hemiarthroplasty of the hip. A prospective, controlled trial of cemented and uncemented prostheses.