Anesth Analg 2002;95:497
© 2002 International Anesthesia Research Society
LETTERS TO THE EDITOR
Hydrogen Peroxide Irrigation: Avoid It or Be Prepared for It?
Prakash K. Dubey, MD
Department of Anesthesiology and CCM, Indira Gandhi Institute of Medical Sciences, Patna, INDIA
To The Editor: I read with interest the article by Sastre et al. (1) describing a case of left-sided gas embolism after surgical lavage of the thoracic cavity with hydrogen peroxide. It was indeed a case of direct left-sided oxygen embolism. It is known that 0.5 to 1 mL of air entering the pulmonary veins can cause coronary embolism and cardiac arrest (2). Even a few mL of hydrogen peroxide 1% was sufficient to produce enough oxygen to cause the symptoms described. The first thing observed immediately after hydrogen peroxide irrigation was an increase in ST segment in ECG lead II, III and aVF. This must have been caused by coronary oxygen embolism.
It is rather strange that even after publication of a series of case reports highlighting the hazards of hydrogen peroxide irrigation, it is being used freely to irrigate surgical fields ranging from posterior cranial fossa (3) to the pleural cavity (1). Fortunately in this patient, the transesophageal echocardiography probe was in position to detect the mishap and detect it quickly and conclusively. Perhaps it is time we prepare a protocol to be followed when hydrogen peroxide is being used intraoperatively for irrigation because early detection and prompt measures has helped in avoiding an adverse outcome in most of the cases reported so far.
References
- Sastre JA, Prieto MA, Garzon JC. Left-sided cardiac gas embolism produced by hydrogen peroxide: intraoperative diagnosis using transesophageal echocardiography. Anesth Analg 2001; 93: 1132–4.[Abstract/Free Full Text]
- Goldfarb B, Bahnson HT. Early and late effects on the heart of small amounts of air in the coronary circulation. J Thorac Cardiovasc Surg 1980; 80: 708–17.[Abstract]
- Dubey PK, Singh AK. Venous oxygen embolism due to hydrogen peroxide irrigation during posterior fossa surgery. J Neurosurg Anesthesiol 2000; 12 (1): 54–6.[Web of Science][Medline]
Response
José A. Sastre Rincón, MBBS,
María A. Prieto Rodrigo, MBBS,
José C. Garzón Sánchez, MBBS, and
Clemente Muriel Villoria, MD Professor
Anesthesiology Service, Hospital Universitario de Salamanca, Salamanca, Spain
In Response: We appreciate the interesting comments of Dubey about our article (1). Certainly, we fully agree that our case was a direct left-sided oxygen embolism and the cardiac arrest must have been produced by a right coronary oxygen embolism.
In our hospital, cardiac surgeons usually use a mixture of saline and povidone-iodine as wound irrigation solution. Surgeon used the H2O2, in our case, in order to remove the great amount of clots and improve the field visualization and facilitate the localization of bleeding site. This is a common practice in neurosurgery and in endoscopic procedures (2).
Hydrogen peroxide is an agent with a weak germicidal effect, and its use do not offer any advantage with respect to other antiseptics (3). This fact, and the wide literature reported about the hazards of hydrogen peroxide irrigation should advise against their freely use in surgery. We think that, perhaps, the most suitable answer to the question that you raise should be: the best preparation to reduce the hydrogen peroxide hazards is to avoid it.
References
- Sastre JA, Prieto MA, Garzón JC, Muriel C. Left-sided cardiac gas embolism produced by hydrogen peroxide: intraoperative diagnosis using transesophageal echocardiography. Anesth Analg 2001; 93: 1132–1134.
- Wu DC, Lu CY, Su YC, Perng DS, Wang WM, Liu CS, Jan CM. Endoscopic hydrogen peroxide spray may facilitate localization of the bleeding site in acute upper gastrointestinal bleeding. Endoscopy 1999; 31: 237–241.[Medline]
- Taylor GJ, Leeming JP, Bannister GC. Effect of antiseptics, ultraviolet light and lavage on airborne bacteria in a model wound. J Bone Joint Surg Br 1993; 75: 724–730.[Medline]
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