Background and Aims We present a case of a complication of bone cement implantation syndrome (BCIS) Grade 3. Its incidence has been suggested to be between 0.14%-0.68% for cemented total hip arthroplasty, with intraoperative mortality of 0.1%¹. Clinical features of BCIS may include hypoxia, hypotension, arrhythmias, increased pulmonary vascular resistance and cardiac arrest. Dyspnoea and altered sensorium can be the first signs in the awake patient². Common risk factors include old age, poor pre-existing physical reserve and impaired cardiopulmonary function².

Methods A 86-year-old woman, severely frail, totally dependent³, with dementia, cardiac and renal impairment, underwent a total cemented left hip arthroplasty due to a femur fracture. A subarachnoid block was performed, and she maintained an hypotensive hemodynamic before and during the surgery. Suddenly the patient went into cardiac arrest as the cement was inserted with altered conscience and ventilation.

Results Immediate cardiopulmonary resuscitation (CPR) was performed, with intubation and mechanical ventilation. Intraoperative transthoracic echocardiograph detected acute pulmonary embolism with pulmonary hypertension. Heparin fibrinolysis was started but it was not possible to restablish stable hemodynamics and after two CPR sequences the patient died in the operating room.

Conclusions Orthopaedic surgeons and anaesthesiologists should recognize the clinical presentation of BCIS and be prepared for its management⁴. Preoperative optimization by increasing oxygen inspiration concentration, communication in advance of the implantation of cement during operation, hemodynamics improved by usage of inotropes and vasopressors and avoiding of intravascular volume depletion⁵ are essential to reduce the incidence and consequences of this rare complication.