DP17: DELAYED BONE CEMENT IMPLANTATION SYNDROME IN THE PACU: A CASE OF POSTOPERATIVE HYPOXIA AND HYPOTENSION FOLLOWING CEMENTED HIP HEMIARTHROPLASTY
Omar Chahine, DO1; Tyler Chonis, MD1; Adith Balaji2
1HCA Kendall Hospital; 2Medical University of the Americas
Introduction: Bone Cement Implantation Syndrome (BCIS) is a recognized complication associated with polymethyl methacrylate (PMMA) use in orthopedic procedures, particularly hip arthroplasties. Typically identified intraoperatively, delayed presentations in the post-anesthesia care unit (PACU) are less common. This case highlights a patient who developed mild to moderate BCIS in the PACU, emphasizing the need for postoperative vigilance in high-risk individuals.
Case Presentation: A 78-year-old female with osteoporosis, hypertension, chronic kidney disease (CKD stage 3), and anxiety underwent a cemented hip hemiarthroplasty after a low-energy femoral neck fracture. She was classified as ASA III preoperatively, with normal sinus rhythm on ECG and a prior echocardiogram showing mild diastolic dysfunction with an ejection fraction of 55%. Her baseline blood pressure was 140/80 mmHg, and room air SpO2 was 98%.
She received spinal anesthesia with 0.75% hyperbaric bupivacaine (12 mg) and intravenous sedation (propofol infusion and midazolam 2 mg IV). Oxygen was administered via nasal cannula. Bone cement application was uneventful, and intraoperative vital signs remained stable (BP 110-140/70-85 mmHg) with minimal vasopressor use. The procedure was completed without complications.
Fifteen minutes after PACU arrival, the patient developed hypoxia, with SpO2 dropping from 97% (on 2L NC) to 86-88%, along with mild tachypnea (RR 24). She also experienced mild hypotension, with BP decreasing from 130/80 mmHg to 80/45 mmHg, tachycardia (HR increased to 110 bpm from 75 bpm), and mild confusion. Differential diagnoses included opioid-induced respiratory depression, post-spinal hypotension, anemia from blood loss, pulmonary embolism, and delayed BCIS.
Her oxygen therapy was escalated to 6L via facemask, improving SpO2 to 93%. A 500 mL lactated Ringer’s bolus was administered, improving BP to 90/55 mmHg. A bedside point-of-care ultrasound (POCUS) revealed mild right ventricular dilation, raising suspicion for microembolic BCIS rather than opioid-related hypoventilation. Her condition improved within an hour with supportive measures. She was transferred to the floor for continued observation without further complications.
Discussion & Learning Points: Delayed BCIS can present in the PACU, often mimicking other postoperative complications. BCIS results from microembolization of marrow contents and cement particles, leading to transient pulmonary hypertension, right heart strain, hypoxia, hypotension, and confusion. Mild cases are self-limiting and resolve with supportive care.
Risk factors include advanced age, osteoporosis, renal dysfunction affecting vasoactive mediator clearance, and preexisting cardiac dysfunction. Preventative measures include maintaining hydration before cement application, considering prophylactic vasopressors in high-risk patients, and ensuring close postoperative monitoring. Delayed presentations necessitate extended PACU observation.
BCIS is categorized into three grades: mild, moderate, and severe. Mild cases present with transient hypoxia and hypotension responding to supportive care. Moderate cases require vasopressor support, while severe cases may progress to cardiovascular collapse. Early recognition and management, including hemodynamic stabilization with fluids and vasopressors, are crucial.
Conclusion: This case underscores the importance of recognizing delayed BCIS in the PACU. Clinicians should be aware of BCIS in at-risk patients who develop sudden postoperative hypoxia and hypotension. Prompt identification and supportive management prevent deterioration and improve outcomes. Increased intraoperative and postoperative vigilance can reduce BCIS-related complications and ensure a safer perioperative course.