Anesthesiology APPLIED Exam › Ambulatory, non-OR and special populations

Bone cement, tourniquets and hip fracture

Ambulatory, non-OR and special populations·~4 min read· Physician-reviewed✓ Sourced · 3

Stem

An 87-year-old woman, 54 kg, fell at home and has a displaced femoral neck fracture; she is scheduled for a cemented hemiarthroplasty. She has heart failure with a preserved ejection fraction, takes furosemide and lisinopril, and has mild cognitive impairment. Blood pressure is 128/70, heart rate 88, saturation 94% on room air. The surgeon plans to cement the femoral stem.

Question

What is your concern about cementing in this patient, and how will you reduce and manage that risk?

Ideal answer

HeadlineBone cement implantation syndrome: hypoxemia, hypotension and possible collapse at cementing. She is high risk: old, cardiopulmonary disease, a diuretic.¹ I plan for it with the team.

Fascia iliaca block before positioning, because it reduces pain on movement and acute confusion.²
Raise her risk at the team briefing, so everyone knows their role if she collapses.
Arterial line; systolic within 20% of pre-induction, spinal or general, kept well filled with fluid and a vasopressor infusion.¹
Agree the cementing technique with the surgeon: warn me first, pressurized lavage and dry canal, cement gun with distal suction catheter and intramedullary plug, no excessive pressurization in her.¹
At cementing, more inspired oxygen and epinephrine drawn up, because collapse is acute right heart failure; epinephrine comes first.

Watch for: falling systolic pressure or a sudden drop in end-tidal CO2, my early warning of right heart failure.¹

Breaking down the answer

Name it and grade it — grade 1 is saturation below 94% or a systolic fall over 20%; grade 2 below 88%, a fall over 40% or loss of consciousness; grade 3 needs CPR.¹ Grading shows organization.
Who is at risk — increasing age, male sex, significant cardiopulmonary disease and diuretic use.¹ She has three of the four.
Team problem — the briefing, a WHO checklist time-out and agreed roles for a severe reaction are part of the guideline;¹ this is where communication is scored.
Technique cuts embolic load — retrograde cementing and gentle pressurization matter.¹ Changes if she is very high risk: an uncemented stem is a reasonable discussion.
The block's evidence — peripheral nerve blocks cut pain on movement by about 2.5 points out of 10 and reduce acute confusion, both high-certainty.²
Why end-tidal CO2 — it falls with cardiac output, so it warns before the cuff; invasive pressure is for higher-risk patients.¹

Follow-up question

Thirty seconds after the stem is inserted, her saturation falls to 82%, the arterial pressure drops to 58/30, and end-tidal CO2 falls from 36 to 18 mmHg.

What do you do?

Follow-up answer

HeadlineGrade 2 bone cement implantation syndrome nearing grade 3: emboli raised pulmonary resistance, her RV is failing.¹ I tell the room, call for help.

I ask the surgeon to stop, give 100% oxygen, and secure the airway if she is under spinal. I treat the right ventricle with the vasopressors the guideline asks to have ready: epinephrine in small boluses, then an infusion.¹ I restore coronary perfusion pressure and give fluid cautiously, because an overdistended right ventricle gets worse. Pulseless, CPR with the roles agreed at the briefing. Once stable: TEE or transthoracic echo to confirm RV dysfunction, a blood gas, and ICU care.

Pitfalls that cost points

Treating the hypotension with large fluid boluses alone.
Choosing neuraxial anesthesia and claiming it prevents the syndrome.

Rapid-fire

Q: What pressures are used for limb tourniquets? A: Commonly about 50 mmHg above systolic for the arm and 100 mmHg above for the leg, upper limits around 200 and 250 mmHg.³

Q: How long can a tourniquet stay up? A: Continuous inflation should not exceed 1.5–2 hours.³

Q: When does tourniquet pain appear? A: At a mean of about 31 minutes after inflation; under general anesthesia, rising heart rate and blood pressure, often resistant to deeper anesthesia.³

Q: What happens on deflation? A: End-tidal CO2 rises, peaking at 1 minute; potassium and lactate rise; blood pressure and core temperature fall transiently.³

Q: Who should not have a tourniquet? A: Sickle cell disease, severe peripheral vascular disease, a prior limb bypass, osteogenesis imperfecta; caution after DVT.³

Numbers to know

Item	Value
BCIS grade 1	SpO2 <94% or SBP fall >20%¹
BCIS grade 2	SpO2 <88%, SBP fall >40%, or loss of consciousness¹
BCIS grade 3	Needs CPR¹
Incidence by grade	~20%, ~3%, ~1%¹
SBP target	Within 20% of pre-induction¹
Tourniquet time	≤1.5–2 h continuous³
Tourniquet pain	Mean ~31 min after inflation³
Potassium after deflation	Mean rise 0.28 mmol/L³

Sources

1.Safety guideline: reducing the risk from cemented hemiarthroplasty for hip fracture 2015 · AAGBI, BOA and BGS, 2015 · anaesthetists.orgGriffiths R, et al. Anaesthesia 2015; BCIS grading in Table 1.
2.Peripheral nerve blocks for hip fractures in adults (plain language summary) · Cochrane, 2020 · cochrane.org
3.Perioperative tourniquet use · OpenAnesthesia · openanesthesia.org

Facts on this page were checked against these sources on Oct 15, 2026. Guidelines change; confirm doses against current institutional protocols.