Anesthesia Incident Reporting System Case 2023-12: Bone Cement Implantation Syndrome

A 78-year-old male presented with a right femoral head fracture after recent fall. PMH included heart failure with reduced ejection fraction (EF 28%), COPD, hypertension, Type II DM, and chronic renal insufficiency. Outpatient medications included furosemide, quinapril, empagliflozin, and albuterol MDI. The patient was admitted and scheduled for right hemiarthroplasty. Preoperative vital signs, Hgb, platelets, and coagulation factors were all within normal limits. In the OR, spinal anesthesia was placed, and the patient was sedated with a propofol infusion. Shortly after injection of bone cement, the patient's BP dropped to 85/50, HR 48, and end tidal CO₂ was no longer detectable. Intravenous phenylephrine and ephedrine boluses were ineffective. Oxygen saturation dropped to 80%. Cardiac arrest ensued, and intubation and chest compressions were initiated. Epinephrine boluses were given. An emergently placed transesophageal echo (TEE) showed significant tricuspid regurgitation, a severely distended right ventricle, and interventricular septum shift with reduced LV...