The Dangers of Hydrogen Peroxide

Hydrogen peroxide irrigation is commonly utilised in neurosurgical procedures and non-neurosurgical procedures for its bacteriocidal and hemostatic effect, however it has been associated with devastating complications such as tension pneumocephalus, O2 embolism and even dysrhythmias 1) 2).
Cardiovascular complications are not rare with an incidence of 3%. Special reference is given to the occurrence of the trigeminocardiac reflex(TCR) in this context 3).
Kleffman et al, present the case of an 81-year-old female patient who underwent lumbar spine surgery (microsurgical decompression) in an external hospital. H2O2 was used during the procedure. The patient was transferred to our hospital. She remained unconscious postoperatively, with progressive loss of brainstem reflexesCT showed intraduraland extradurally trapped air ascending intradural from the operated lumbar segment up to frontal lobeMRI demonstrated severe brainstem lesions on T2– and diffusion weighted magnetic resonance imaging. The patient died 10 days after surgery. Autopsy was not performed.
This case demonstrates a fatal complication with ischemic brainstem lesions and pneumocephalus following use of hydrogen peroxide. Therefore, H2O2 should only be used in cases without any signs of dural injury 4).
Patankar et al., report a case of air-embolism and subsequent ischaemic damage to the brain following intra-operative irrigation with hydrogen peroxide within a closed cavity of a spinal cold abscess of tuberculous origin. Copious amount of undiluted hydrogen peroxide irrigation was deployed under moderate pressure to clean-up the abscess cavity. Post-operatively, the patient developed seizures followed by clinical and radiological features of brain ischaemia ultimately resulting in a fatal outcome 5).
1) Huang C, Pik J. Tension pneumocephalus and oxygen emboli from hydrogen peroxide irrigation. J Clin Neurosci. 2014 Feb;21(2):323-5. doi: 10.1016/j.jocn.2012.10.044. Epub 2013 Jun 14. PubMed PMID: 23751899.
2) Gyanesh P, Haldar R. Hemodynamic derangements with hydrogen peroxide instillation in neurosurgery: need for awareness among anesthesiologists and surgeons. World Neurosurg. 2014 Jul-Aug;82(1-2):e388-9. doi: 10.1016/j.wneu.2012.10.070. Epub 2012 Oct 27. PubMed PMID: 23111214.
3) Spiriev T, Prabhakar H, Sandu N, Tzekov C, Kondoff S, Laleva L, Schaller B. Use of hydrogen peroxide in neurosurgery: case series of cardiovascular complications. JRSM Short Rep. 2012 Jan;3(1):6. doi: 10.1258/shorts.2011.011094. Epub 2012 Jan 24. PubMed PMID: 22299072; PubMed Central PMCID: PMC3269103.
4) Kleffmann J, Ferbert A, Deinsberger W, Roth C. Extensive ischemic brainstem lesions and pneumocephalus after application of hydrogen peroxide H202 during lumbar spinal surgery. Spine J. 2014 Dec 5. pii: S1529-9430(14)01776-8. doi: 10.1016/j.spinee.2014.12.006. [Epub ahead of print] PubMed PMID: 25485485.
5) Patankar PS, Joshi SS, Choudhari KA. Air-embolism and cerebral ischaemia following epidural hydrogen peroxide irrigation in a closed lumbar cavity. Br J Neurosurg. 2014 Aug;28(4):556-8. doi: 10.3109/02688697.2013.865706. Epub 2013 Dec 5. PubMed PMID: 24304268.

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