Hydrogen peroxide-induced air embolism and cardiovascular collapse in a pediatric patient; a case report

A 6-month old male patient with a history of recurrent scrotal abscess presented for cystoscopy, incision and debridement at Children’s Hospital of Orange County in August 2016. Past medical history includes premature... [ view full abstract ]

A 6-month old male patient with a history of recurrent scrotal abscess presented for cystoscopy, incision and debridement at Children’s Hospital of Orange County in August 2016. Past medical history includes premature delivery at 31 weeks, with 6-week NICU stay for feeding and 1 week CPAP for apneic episodes with uneventful discharge. Past surgical history includes drainage of scrotal abscess one month prior with uneventful perioperative hospital stay. The patient underwent smooth mask induction with sevoflurane. LMA was placed easily and patient was then turned 90 degrees for procedure. No caudal block was attempted. Shortly after incision, patient developed wheezing and high peak airway pressure despite appropriate anesthetic depth with sevoflurance and fentanyl. CPAP and propofol given with respiratory improvement. Patient was electively intubated uneventfully on first attempt. Albuterol given and wheezing resolved. Procedure continued to be well tolerated until scrotal abscess was irrigated with non-diluted 3% hydrogen peroxide. Subsequently, the patient desaturated to 70-80% and briefly became cyanotic. End-tidal CO2 suddenly decreased to nadir of 8. Additional anesthesia help was called immediately. Breath sounds were confirmed as clear bilaterally with normal peak pressures and appropriate tidal volumes. Total of 20 mcg epinephrine was given and titrated in 5 mcg increments. ETCO2 slowly returned to baseline while HR and BP remained stable throughout. Patient’s color soon returned and saturations improved to mid-90s. Drapes were immediately removed and scrotum was noted to be severely swollen, distended, and discolored. Exam was significant for crepitus. STAT chest and abdominal films were taken in OR and demonstrated extensive soft tissue gas dissecting into the left inguinal canal and left lower quardrant of the pelvis. Hydrogen peroxide induced oxygen vs air embolism suspected. Patient was observed in the OR for an additional 30 mins after procedure stop time and remained hemodynamically stable with return to baseline ETCO2 waveform. Decision was made in discussion with urology team to keep patient intubated and transfer to ICU. Transport was uneventful and transfer of care was completed to PICU team. Postoperative echocardiogram was obtained and showed patent foramen ovale versus small secundum atrial septal defect with left to right shunting with normal right and left ventricular size and function. Postoperative course was uneventful. Patient was extubated on postoperative day one and was stable for discharged home.

Discussion: 

Hydrogen peroxide induced air embolism mechanism
Review of case reports