Total Knee Arthroplasty Revision in the Setting of Periprosthetic Joint Infection Resulting in Bone Cement Implantation Syndrome (BCIS), Pulseless Electrical Activity (PEA) Arrest, and Intraoperative Death: A Case Report and Literature Review

Abstract

An 87-year-old female with a history of total knee arthroplasty (TKA) presented to the emergency department (ED) for left knee pain in the setting of recent methicillin-sensitive Staphylococcus aureus (MSSA) sepsis of unknown origin. She was subsequently diagnosed with a complicated symptomatic periprosthetic joint infection of her left TKA hardware and was admitted for TKA revision following an orthopedic surgery consultation. Upon arrival at the operating room (OR), standard American Society of Anesthesiology (ASA) monitors were applied. These included non-invasive blood pressure, electrocardiogram (ECG), pulse oximeter, and an esophageal temperature probe. The patient then underwent induction of general endotracheal anesthesia (GETA) without significant hemodynamic compromise. Intraoperatively, the patient tolerated the removal of her infected hardware without major complication but upon placement of the methyl methacrylate (MMA), commonly referred to as bone cement, the patient had an acute drop in her end-tidal carbon dioxide (EtCO ₂) and then developed significant bradycardia and hypotension. Despite rapid detection and treatment, the patient continued to collapse hemodynamically and was noted to be pulseless and in pulseless electrical activity (PEA) arrest on ECG. Cardiopulmonary resuscitation (CPR) was immediately started per the Advanced Cardiac Life Support (ACLS) algorithm. Roughly after 45 minutes of continuous CPR and multiple doses of 1 mg epinephrine, it was determined that the patient had suffered a catastrophic and fatal intraoperative event. A team decision was made to stop providing any lifesaving interventions. This patient’s presentation is consistent with bone cement implantation syndrome (BCIS), an uncommon phenomenon that remains poorly understood. Two leading models for BCIS described in the literature are the monomer-mediated and embolus-mediated models. However, further research into BCIS is warranted to better understand its pathophysiology, incidence, as well as potential prophylactic measures, including the use of cementless arthroplasty. This complicated and fatal case serves as a reminder of the morbidity and mortality associated with BCIS and underscores that anesthesiology teams must remain vigilant and prepared during orthopedic joint procedures.