Hyperbaric oxygen therapy for systemic gas embolism after hydrogen peroxide ingestion

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

INTRODUCTION

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.

PRESENTATION OF CASE

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.

DISCUSSION

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.

CONCLUSION

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.

Timing of embolic phenomena after hydrogen peroxide exposure - a systematic review

INTRODUCTION

Hydrogen peroxide ingestions cause significant morbidity and mortality due to oxygen gas emboli and are treatable with hyperbaric oxygen therapy. Recommendations for observation are based on small case series.

OBJECTIVES

The aim of this systematic review is to define the time of onset of embolic phenomena after hydrogen peroxide exposure and to describe the proportion of patients who received hyperbaric oxygen therapy.

METHODS

Cases from a systematic literature search were combined with those from a prior study that used data derived from the American Association of Poison Control Centers National Poison Data System. Air-gas emboli were defined as embolic phenomena (stroke, myocardial infarction, obstructive shock) potentially reversed with hyperbaric oxygen therapy. Simple counts, mean, and interquartile range were used for description and comparisons.

RESULTS

A total of 766 records were identified in the literature search. Three-hundred and eighty-three duplicate records were identified and removed. Of the 383 remaining records, 156 met inclusion criteria; 88 were excluded based on predetermined criteria yielding 68 records with 85 unique cases. Forty-one cases were extracted from the 2017 National Poison Data System study resulting in a total of 126 cases for analysis. Case descriptions: We analyzed these 126 cases and documented 213 discrete clinical events, excluding deaths. There were 108 high-concentration exposures, 10 low-concentration exposures, and 8 were unknown. Thirty-five cases were intentional ingestions but not for self-harm, and 84 were unintentional or accidental. Only 4 cases were for self-harm, and there were 23 pediatric cases. There were 99 air-gas emboli reported in 78 patients. Time to onset: The time to onset of air-gas embolic was documented in 70/78. Time to symptom onset ranged from immediate to 72 h after hydrogen peroxide exposure. Over 90% of embolic symptoms occurred within 10 h of ingestion. Hyperbaric oxygen therapy: A total of 54/126 cases received hyperbaric oxygen therapy. Of those 54 cases, 31 had primary portal venous gas while the remaining 23 had air-gas emboli. Of the 23 air-gas emboli cases treated with hyperbaric oxygen therapy, 13 made full recoveries while 10 had residual symptoms or died. Mean time from air-gas emboli symptom onset to hyperbaric oxygen therapy in the full recovery group was 9 h compared to 18.2 h in the partial recovery/death group. Portal venous gas: There were 63 total reported cases of portal venous gas. Forty-nine of these cases were primary portal venous gas, 13 were secondary findings in patients with air-gas emboli and one case was secondary to non-air-gas emboli symptoms. Twenty-seven of 49 patients with portal venous gas (55%) as the primary finding had gastrointestinal bleeding. Thirty of the 63 cases received hyperbaric oxygen therapy for portal venous gas without any documented air-gas emboli. Deaths: Seventeen deaths occurred in the combined cohort. Of these, 13 were associated with high-concentration exposures. All deaths with reported time to symptom onset had symptoms within 1 h of exposure.

CONCLUSION

This review of hydrogen peroxide exposure cases suggests that clinically significant embolic phenomena occur within 10 h of exposure, although delayed air-gas emboli do happen and should considered when deciding duration of observation. It remains equivocal whether hyperbaric oxygen therapy is beneficial in cases of primary portal venous gas without systemic involvement.

Gastric Pneumatosis After Accidental Ingestion of Concentrated Hydrogen Peroxide: A Case Report

Introduction

Hydrogen peroxide is a common oxidizing agent that if ingested may cause injury to the gastrointestinal tract or embolic events. Although therapy is primarily supportive, gastric perforation is a rare but serious complication of corrosive ingestion that may require surgical treatment.

Case Report

We report the case of a 77-year-old male who presented for nausea and vomiting after accidentally ingesting approximately 150 milliliters of 35% hydrogen peroxide. Computed tomography revealed gastric pneumatosis and extensive portal venous air. The patient was admitted for observation with plans for endoscopy; however, due to the limitations of our small community hospital, he was transferred to a tertiary care center due to concern for a potential gastric perforation.

Conclusion

The presence of portal venous air as a result of peroxide ingestion may be treated conservatively depending on presenting symptoms; however, severe injury such as gastrointestinal perforation may necessitate surgical intervention.

Acute Respiratory Failure after Administration of Hydrogen Peroxide as an Emetic in a Cat

OBJECTIVE AND CASE SUMMARY

This case report describes a 5-year-old domestic short-haired cat that was orally administered with 4 mL of 3% hydrogen peroxide by the owner after suspecting ingestion of a foreign body by the cat. Shortly after the administration, the cat developed severe respiratory distress. Thoracic radiography showed an interstitial-to-alveolar pulmonary pattern, while echocardiography and heart injury markers ruled out a cardiac origin. Intensive management with oxygen, diuretics, bronchodilators, and sedation resulted in survival of the cat without further respiratory complications.

NEW AND UNIQUE INFORMATION PROVIDED

To the best of our knowledge, this is the first report of a lung injury and acute respiratory failure after administration of hydrogen peroxide in a cat with successful management.

Hydrogen peroxide ingestion with injury to upper gastrointestinal tract

Hydrogen peroxide is a common over-the-counter solution that has developed a growing body of literature regarding toxic ingestion. Intentional ingestion of high concentration hydrogen peroxide for health purposes has gained popularity in certain patient populations; purported benefits are due to the increased oxygen released into the blood stream. We present for evaluation one such case with associated imaging that presented to our urban medical center. A brief review of the literature was also performed noting current recommendations regarding both outcomes and indications for endoscopy as well as hyperbaric oxygen therapy following ingestion of hydrogen peroxide. Our patient was a 51-year-old white female who presented with foamy hematemesis after ingesting 10 drops of 35% hydrogen peroxide as part of a home remedy to cleanse her colon and improve blood oxygenation. In addition to hematemesis, she also reported diffuse abdominal pain with sore throat and hoarse voice. Her imaging demonstrated portal venous gas and gastric edema. She was admitted for hyperbaric oxygen therapy and underwent upper endoscopy demonstrating diffuse esophagitis and gastritis with white exudate and multiple petechiae. She was later discharged home in stable condition and was lost to follow-up.

Serotonin Syndrome from 5-Hydroxytryptophan Supplement Ingestion in a 9-Month-Old Labrador Retriever

INTRODUCTION

5-Hydroxytryptophan (5-HTP) supplements are available over the counter and labeled as sleeping aids and anxiolytics for human use. 5-HTP is a serotonin precursor and overdose can lead to serotonin syndrome.

CASE REPORT

A 9-month-old female Labrador retriever was evaluated after ingestion of a 5-HTP supplement. Signs of agitation developed within 1 h of ingestion, and emesis was attempted by the owner with  3% hydrogen peroxide (H₂O₂) orally. On presentation, the dog was obtunded, bilaterally mydriatic and salivating. Physical exam revealed tachypnea, tachycardia, hyperthermia, and hypertension. Eighteen hours post presentation, the dog developed melena, hematemesis, and pigmenturia. A hemogram revealed mild anemia with evidence of oxidative erythrocyte damage (eccentrocytes, Heinz bodies, and siderocytes). A chemistry panel revealed markedly elevated creatine kinase and hyperbilirubinemia, supporting hemolytic anemia. A urinalysis revealed pigmenturia. Hemolytic anemia was presumed to be caused by oxidative damage secondary to gastrointestinal ulceration and circulatory embolism of H₂O₂. Treatment included fluid therapy, a mannitol constant rate infusion, antiemetics, gastroprotectants, and cyproheptadine as a serotonin antagonist. The patient responded well to treatment and was discharged within 48 h of presentation.

DISCUSSION

Serotonin syndrome is an increasingly common toxic syndrome in veterinary medicine with the availability of over-the-counter medications that alter serotonin metabolism. The importance of appropriate client education regarding emesis with H₂O₂ is highlighted.

Hyperbaric oxygen therapy for the prevention of arterial gas embolism in food grade hydrogen peroxide ingestion

Food grade hydrogen peroxide ingestion is a relatively rare presentation to the emergency department. There are no defined guidelines at this time regarding the treatment of such exposures, and providers may not be familiar with the potential complications associated with high concentration hydrogen peroxide ingestions. In this case series, we describe four patients who consumed 35% hydrogen peroxide, presented to the emergency department, and were treated with hyperbaric oxygen therapy. Two of the four patients were critically ill requiring intubation. All four patients had evidence on CT or ultrasound of venous gas emboli and intubated patients were treated as if they had an arterial gas embolism since an exam could not be followed. After hyperbaric oxygen therapy each patient was discharged from the hospital neurologically intact with no other associated organ injuries related to vascular gas emboli. Hyperbaric oxygen therapy is an effective treatment for patients with vascular gas emboli after high concentration hydrogen peroxide ingestion. It is the treatment of choice for any impending, suspected, or diagnosed arterial gas embolism. Further research is needed to determine which patients with portal venous gas emboli should be treated with hyperbaric oxygen therapy.