O2094: A Sticky Situation: Bone Cement Embolization Leading to Cardiac Arrest in a Pediatric Patient

Introduction: Bone graft cement is commonly used in orthopedic surgery to enhance structural integrity and promote bone healing. Bone cement implantation syndrome (BCIS) is thought to arise from embolic material entering the venous system during cement pressurization, leading to cardiopulmonary instability. Here, we present a rare case of bone graft cement embolization in a pediatric patient leading to cardiac arrest.

Case Description: A previously healthy 7-year-old male presented to the OR for an elective needle biopsy of a recently diagnosed aneurysmal bone cyst in the left tibia. He tolerated induction unto general anesthesia well. Three needles were used to connect and vent the cyst cavities. A foam solution of doxycycline, saline, and albumin was injected into the cyst. Bone graft cement was then injected through each needle then left to vent for five minutes. During this venting period, the patient developed acute bradycardia and desaturations progressing to pulseless electrical activity. CPR was initiated. Patient subsequently developed ventricular fibrillation refractory to defibrillation prompting ECPR initiation. In the PICU, the patient was sedated, anticoagulated and supported on veno-arterial ECMO. EEG showed diffuse cortical dysfunction, and head CT revealed multiple infarcts. Chest CT demonstrated hyperdensities in the right atrium, right ventricle, and lungs, consistent with bone cement embolization. Due to the extent of embolization, no surgical options were able to be offered. As neurological status declined, the family elected to withdraw care. Cause of death was determined to be bone graft cement embolization leading to cardiac arrest and hypoxic-ischemic encephalopathy (HIE).

Discussion: Bone cement embolization is a well-documented but uncommon complication typically in adult populations with osteoporotic or metastatic vertebral fractures. Its occurrence in pediatric patients is exceedingly rare, with very few cases reported.. This case highlights a tragic outcome of cement embolization in a pediatric patient, emphasizing the importance of recognizing that this risk is not limited to adults.
The pathophysiology involves the inadvertent extravasation of polymethylmethacrylate (PMMA) cement into the venous system, which can then embolize to the pulmonary arteries or cardiac chambers. In children, the smaller vessel caliber and distinct hemodynamic characteristics may predispose to more severe consequences, even with small volumes of embolized cement.
While asymptomatic emboli may be managed conservatively, symptomatic cases—particularly those involving cardiopulmonary compromise—require urgent intervention, which may not always be successful, as in this case.
Early recognition of embolization signs—such as decreased end-tidal CO₂, hypoxia, hypotension, and arrhythmias—is essential. Prompt resuscitation and early ECPR initiation may improve outcomes. However, in this case, the extent of embolization was overwhelming and ultimately fatal.

Conclusion: Bone cement embolization, though rare in pediatric patients, can lead to fatal outcomes. This case highlights the need for heightened awareness and close monitoring to reduce the risk of this serious complication.