Simultaneous gas embolism and pneumocephalus after paravertebral irrigation with hydrogen peroxide: A rare case report

• Published in: International journal of surgery case reports 2024-03, Vol.116, p.109387, Article 109387
• Main Authors: Zhang, Kai, Jia, Haitao
• Format: Article
• Language: English
• Subjects: Cardiac arrest; Gas embolism; Hydrogen peroxide; Pneumocephalus; Spine; Tuberculosis
• ISSN: 2210-2612; 2210-2612
• DOI: 10.1016/j.ijscr.2024.109387

Gas embolism is a rare but fatal clinical emergency. Hydrogen peroxide (H2O2) can cause gas embolism when improperly used in closed cavities or for deep and large wound irrigation. A 31-year-old woman was diagnosed with lumbar-3 tuberculosis and paravertebral abscess and underwent emergency spinal surgery in a prone position. After removing the tuberculous pus, 200 mL of H2O2 (3 % v/w) was used to repeatedly irrigate the abscess cavity. Immediately after irrigation, the patient suffered cardiac arrest. During cardiopulmonary resuscitation, transesophageal echocardiography revealed that the right cardiac cavity was filled with a diffuse “Snowflake-Like” gas embolus, and cranial computed tomography showed a multi-point pneumocephalus in the frontal lobes. The patient eventually suffered brain death despite the return of spontaneous circulation after active resuscitation. H2O2 can quickly release abundant oxygen and water upon contact with catalase. Oxygen bubbles enter the vascular lumen and cause mechanical obstruction of the right cardiac circulation. In addition, H2O2 and oxygen bubbles may migrate upwards and enter the intracranial tissue through the epidural space or subdural space, resulting in intracranial pneumatosis. Diagnosis and treatment of gas embolism are extremely difficult. Some suggestions are that H2O2 should not be used in closed cavities or on deep and large wounds due to the potential risk of fatal gas embolism. The fatal complications of gas embolism and pneumocephalus rarely occur simultaneously in one patient, and we aim to highlight this potential risk of intraoperative H2O2 use in spinal surgery. •Gas embolism is a rare but fatal clinical emergency event.•When used inappropriately, hydrogen peroxide could lead to gas embolism.•Cardiac arrest and pneumocephalus co-occur after hydrogen peroxide irrigation.•We should be on guard against these fatal complications of hydrogen peroxide.