Hydrogen peroxide: an unusual cause of arterial and venous gas embolism

Abstract

SummaryA patient undergoing minor orthopaedic surgery suffered from unexpected arterial and venous gas embolism caused by hydrogen peroxide. We describe our management of the case and emphasise the need for continued vigilance during the use of hydrogen peroxide. Key wordsComplications; embolism, oxygen. Pharmacology; hydrogen peroxide.The use of hydrogen peroxide has been associated with a variety of potentially fatal complications such as surgical emphysema and oxygen embolism to various vascular beds of the body [I]. We report the unexpected occurrence of arterial and subsequent venous, oxygen embolism during a case of minor orthopaedic surgery in which the first sign of danger was the visualisation of gas in the vascular tree. Case historyA 22-year-old female patient (55 kg) presented for excision of an infected sinus in the left tibia. Six months previously a Denham pin had been inserted 2cm below the tibia1 tubercle to apply traction for an acetabular fracture following a road traffic accident. The pin was removed after 7 weeks and the patient discharged a few days later.The patient was fit, with no previous medical problems and an ASA 1 status. After oral premedication with metoclopramide 10 mg, ranitidine 150 mg and temazepam 10 mg anaesthesia was induced with midazolam 2 mg, fentanyl 50 pg and propofol 120 mg followed by insertion of a laryngeal mask airway. Arterial oxygen saturation (Spo,), inspiratory oxygen concentration (Ro2), end-tidal carbon dioxide concentration (Fk'co,), noninvasive blood pressure and electrocardiograph (mode V5) monitoring was started in the anaesthetic room and continued throughout the operation. Anaesthesia was maintained with isoflurane 0.7-1.2% in 60% nitrous oxide in oxygen, the patient breathing spontaneously from a Mapleson A breathing system. Morphine analgesia was administered in increments up to 5 mg in total. A tourniquet was applied (250 mmHg pressure) and the surgeon excised infected granulation tissue which was superficial as well as deep inside the former pin tract. The bony wound canal was irrigated with 10 ml of hydrogen peroxide 6% followed by 10 ml of 0.9% saline. After insertion of a Kaltostat wick the wound was closed and a dressing applied. Throughout the operation the patient remained normocapnoeic (Fk'co, 4.9-5.2 kPa), the systolic blood pressure between 95 and 110 mmHg and the pulse rate between 55 and 65 beat.min-I. After 26min operation time the tourniquet was deflated and the drapes removed.Within a few seconds of releasing the tourniquet the surgeon noted that the first and second toe of the foot were white, whereas the rest of the foot was pink. Gas bubbles were then noticed in the veins of the dorsum of the foot followed by a decrease in the end-tidal CO, concentration from 4.9 to 3.6 kPa. Auscultation of the heart revealed a classic 'mill-wheel' murmur. There was no evidence of haemodynamic instability shown by alterations in heart rate, rhythm or blood pressure.The tourniquet was immediately reapplied, the patient put in a left-lateral position...

Hydrogen Peroxide – A Party Trick from the Past?

“…Human catalase is highly efficient, mediating the breakdown of up to 200,000 molecules of hydrogen peroxide per second 2,5 . One millilitre of 3% hydrogen peroxide solution will produce 9.8 millilitres of oxygen 6,7 .…”

“…There are approximately 62 cases described in the international literature of severe morbidity and mortality resulting from intraoperative oxygen embolism, but only two in the Australasian literature 2,6, . This is despite the fact that in the latest report of the Victorian Consultative Council on Anaesthetic Mortality and Morbidity hydrogen peroxide solutions were specifically mentioned in three cases of oxygen embolism 59 .…”

A rare and uncommon complication after use of hydrogen peroxide (H2O2): A review of use of H2O2 in orthopaedics

“…Application of H 2 O 2 to human tissue causes it to rapidly decompose into oxygen and water. 2 –5 It has been reported that as little as 1 mL of 3% H 2 O 2 can release up to 10 mL of oxygen. 4…”

“…2,4 Patients with cardiac shunts (foramen ovale, atrial or ventricular septal defect) are at even higher risk of air embolism resulting in lethal cardiac or respiratory events. 5 Prior authors have cautioned the use of H 2 O 2 in confined spaces due to increased risk of air embolization. 1,2,4 It is believed that the sudden production of gas in an enclosed area results in increased pressure, thereby forcing gas into the blood stream.…”

“…4 If the episode of embolism occurs after the release of the tourniquet, the tourniquet should be reinflated immediately to prevent further dissipation of gas bubbles into the systemic circulation. 5 Anaesthetic management should include discontinuation of nitrous oxide, as this has shown to increase the gas bubble up to fourfold in size 5 and to immediately institute 100% oxygen therapy. 4 The patient should be placed in a left lateral recumbent head down position ( Figure 4) to prevent gas bubbles from entering the pulmonary circulation.…”