CASE REPORTS Left-Sided Cardiac Gas Embolism Produced by Hydrogen Peroxide: Intraoperative Diagnosis Using Transesophageal Echocardiography Jose ´ A. Sastre, MBBS, Marı ´a A. Prieto, MBBS, Jose ´ C. Garzo ´n, MBBS, and Clemente Muriel, MD Anesthesiology Service, University Hospital of Salamanca, Salamanca, Spain T he use of transesophageal echocardiography (TEE) in cardiac surgery permits the evaluation of cardiac anatomy and function and can also be used to diagnose intracardiac shunts, disturbances in valvular function, gas embolism, aortic dissection, and myocardial ischemia (1). TEE can also be a useful technique for detecting problems that occur during the anesthetic or surgical actions. Hydrogen peroxide (H 2 O 2 ) is an oxidizing agent commonly used in wound cleansing because of its germicidal action and, in addition, for its action in bubbling out foreign materials and debris (2). How- ever, its administration has been associated with gas embolism in a variety of procedures (3–10). Case Report A 78-yr-old, 52-kg woman with mitral and aortic valvular disease and chronic atrial fibrillation was scheduled for re- placement of both valves with biological Carpentier protheses. After a normal postoperative course, the patient returned to the intensive care unit a week later because of severe anemia and respiratory insufficiency caused by a massive right hemotho- rax. Thoracic drainage and blood transfusion were performed, followed by an exploratory sternotomy. Anesthesia was in- duced with IV fentanyl 0.15 mg, etomidate 12 mg, and rocu- ronium bromide 30 mg. Maintenance included fentanyl infu- sion 4 g · kg -1 ·h -1 , propofol 4 mg · kg -1 ·h -1 , rocuronium bromide 0.5 mg · kg -1 ·h -1 , and O 2 /N 2 O. Intraoperative mon- itors included electrocardiogram (ECG) leads II and V 5 with ST segment analysis, invasive blood pressure, central venous pres- sure, pulse oximetry, urine output, muscle relaxation, capnog- raphy (Petco 2 ), and TEE by an omniplanar probe (HP Om- niplana II 21369A and Hewlett-Packard Image Point HX; Hewlett-Packard, Andover, MA). After sternal incision, blood and clots were found in the right pleural cavity without an active source of hemorrhage. Examination of the surgical wound disclosed a small tear on the anterior surface of the middle lobe. Before chest closure, the surgeon irrigated the surgical field with 300 mL 1% H 2 O 2 solution. Immediately, a ST segment increase of 3.2 mm was observed in ECG leads II, III and aVF. Coronary vasospasm was suspected. Nitroglycerin 50 g IV was administered, followed by an infusion at a rate of 20 g · kg -1 · min -1 . Two minutes later the patient suffered a severe decrease in blood pressure, bradycardia of 30 bpm, a decrease in pulse oximetry value from 95% to 89%, and a decrease in Petco 2 from 34 mm Hg to 30 mm Hg. Atropine 1 mg and ephedrine 10 mg IV were given. Air bubbles were detected by TEE in left-side structures (Fig. 1, 2). The diagnosis of gas embolism was strongly suspected. One-hundred percent oxygen was administrated and the surgical field was flooded with saline solution. The patient was placed in the Trendelen- burg position to aid in removing gas from the left ventricle by placement of a needle into the apex. Just before insertion of the needle, sudden asystole occurred. Internal cardiac massage was initiated and epinephrine 1 mg IV was given. Within seconds, the patient’s ventricular rate increased to 50 bpm and a small amount of air bubbles exited the left ventricle through the needle. Epicardial electrodes were connected to a pace- maker to increase the heart rate to 80 bpm. In a few minutes ECG abnormalities disappeared and the patient recovered he- modynamic stability. After chest closure, the patient was trans- ferred to the intensive care unit and was tracheally extubated 1 h later. Follow-up evaluation showed no evidence of neuro- logic deficit and no increase of serum cardiac markers. The subsequent clinical course was favorable and the patient was discharged from the hospital 15 days later. Discussion Gas embolism produced by hydrogen peroxide is an uncommon surgical complication that can be ex- plained by a chemical reaction in which hydrogen peroxide decomposes rapidly as a result of the action of catalases in blood and tissues, releasing molecular oxygen and H 2 O: It has been calculated that 1 mL of H 2 O 2 3% pro- duces 10 mL of oxygen in the tissues (3). Air embolism produced by H 2 O 2 has been typically associated with injection under pressure into closed and semiclosed body cavities (7–9). However, life- threatening complications have been reported using Accepted for publication June 13, 2001. Address correspondence and reprint requests to Jose ´ Alfonso Sastre Rinco ´ n, MBBS, Servicio de Anestesiologı ´a, Hospital Univer- sitario de Salamanca, Paseo de San Vicente, 58-182, 37007, Salamanca, Spain. Address e-mail to med026221@nacom.es. ©2001 by the International Anesthesia Research Society 1132 Anesth Analg 2001;93:1132–4 0003-2999/01