Tourniquet physiology, bone cement implantation syndrome, and fat embolism

Meet the patient

An 82-year-old woman with a fractured neck of femur arrives for a cemented hemiarthroplasty. She has pulmonary hypertension and a fixed cardiac output state. The surgeon calls "cement going in" — and within thirty seconds her saturation drops to 88 percent and her systolic pressure falls from 140 to 85. The room goes quiet.^[1]

The question that decides her next minute is the question that decides every orthopaedic crisis: is this the expected physiology of the dangerous moment, or something else? Hold that question — cement, deflation, or the hours after nailing — and the three crises below fall into place.^[1]

References5ShowHide

1. [1]Donaldson AJ et al. Bone cement implantation syndrome Br J Anaesth, 2009.PMID 19059919
2. [2]Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial Lancet, 2010.PMID 20554319
3. [3]Frerk C et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults Br J Anaesth, 2015.PMID 26556848
4. [4]Unterman K, Fada L, Clark KA, et al. Tourniquet Use and Anesthesiology Considerations in Patients With Hypermobile Ehlers-Danlos Syndrome: Balancing Orthopedic Needs With Anesthetic Safety. Cureus, 2026.PMID 41978595
5. [5]Shaikh N, Alali B, Amara UE, et al. Fat Embolism Syndrome: Evolving Perspectives on Diagnosis and Care. Cureus, 2025.PMID 41356881