P039: FROM FIXATION TO COLLAPSE: BONE CEMENT SYNDROME DURING FEMORAL ORIF
Kevin Suarez, MD; Lucas G Nieto, MD; Raul Bermudez, MD
HCA- Florida Kendall Hospital
Introduction: Bone cement implantation syndrome (BCIS) is a rare but potentially fatal complication associated with cemented orthopedic procedures, particularly hip arthroplasty and hemiarthroplasty. Clinically, BCIS is characterized by hypoxia, hypotension, pulmonary hypertension, cardiac arrhythmias, and in severe cases, cardiovascular collapse and cardiac arrest (Donaldson et al., 2009). The syndrome most commonly manifests during cementation, prosthesis insertion, joint reduction, or tourniquet deflation—critical intraoperative periods requiring heightened anesthetic vigilance. Mild forms have been reported in up to 20–30% of cemented hip procedures, whereas severe (grade 3) BCIS is less common but carries mortality rates approaching 50–60%, particularly in elderly patients with limited cardiopulmonary reserve (Jaffe et al., 2022; Rassir et al., 2021).
The pathophysiology of BCIS remains incompletely understood. Proposed mechanisms include embolization of fat, marrow, air, and cement particles into the pulmonary circulation, resulting in increased pulmonary vascular resistance, acute right ventricular dysfunction, reduced left ventricular preload, and systemic hypotension (Parker et al., 2004). Early anesthetic indicators include sudden hypoxemia, hypotension, and a marked decrease in end-tidal carbon dioxide (ETCO2), placing anesthesiologists at the forefront of recognition and intervention.
Methods: This case report describes the perioperative course of an 85-year-old female with multiple comorbidities, including multiple sclerosis, bradyarrhythmia status post pacemaker placement, hypertension, chronic kidney disease stage IIIa, prior cerebrovascular accident, and chronic anticoagulation therapy with apixaban. She presented following a motor vehicle accident resulting in bilateral acute comminuted intra-articular femur fractures.
Preoperative evaluation included cardiology consultation and pacemaker interrogation. The patient was deemed intermediate cardiac risk and classified as ASA Physical Status IV. Baseline vital signs were stable. General anesthesia was induced with fentanyl (25 mcg), etomidate (10 mg), and succinylcholine (100 mg), and intubation was achieved with a Macintosh size 3 blade yielding a grade 2a view. Rocuronium (10 mg), tranexamic acid (1 g), and dexamethasone (4 mg) were administered prior to incision. Standard ASA monitors were used throughout the procedure.
Results: The first side of fixation was completed without complication. Approximately 30 minutes into fixation of the contralateral femur, coinciding with bone cement placement, the patient developed acute hemodynamic instability. Oxygen saturation declined to the mid-50% range, ETCO2 decreased to 15–18 mm Hg, and mean arterial pressures fell to the 30–40 mm Hg range.
Immediate resuscitative measures were initiated, including intravenous fluids, albumin, vasopressors, inotropes, and blood products. Differential diagnoses included pulmonary embolism, fat embolism, and transfusion-related acute lung injury. Given the temporal relationship to cementation and profound cardiovascular collapse, severe BCIS was strongly suspected. The procedure was aborted, and the patient was transported for emergent imaging to evaluate for pulmonary embolism.
Conclusion: This case highlights the abrupt onset and severe hemodynamic consequences of BCIS in a frail elderly patient undergoing cemented orthopedic surgery. The combination of hypoxemia, hypotension, and decreased ETCO2 immediately following cementation was highly consistent with severe BCIS. Prompt recognition, aggressive hemodynamic support, and close interdisciplinary communication remain essential to optimizing outcomes in this high-risk population.