Hydrogen Peroxide in Operative Wounds and Cavities: Oxygen Generation, Gas Embolism, Recognition, Response, and System Safeguards

PREPRINT — This manuscript has not undergone peer review. Hydrogen peroxide is both a topical antiseptic and a rapid oxygen-generating reactant. Contact with tissue catalase can convert approximately 1 mL of 3% solution into 10 mL of oxygen. In closed, pressurized, or vascularly connected operative spaces, this reaction can produce gas embolism with abrupt cardiopulmonary or neurologic deterioration. This narrative patient-safety review connects published operative case reports, toxicology and gas-embolism reviews, regulatory warnings, and perioperative guidance. It examines hazardous anatomy and delivery techniques, recognition through physiologic monitoring, diagnostic limitations, immediate response, and institutional prevention. Management priorities include stopping exposure, preventing further gas entry, administering oxygen, supporting circulation, and obtaining specialist assessment without delaying resuscitation. The review proposes controls for solution selection and labeling, avoidance of hazardous routes and spaces, multidisciplinary communication, and authority to stop unsafe irrigation. A focused team prompt is offered for local evaluation; it is not a validated clinical instrument or an authorization to use peroxide. The evidence cannot establish a reliable incidence, a universally safe operative dose, or the effectiveness of the proposed safeguards. Prevention should therefore combine attention to the documented hazard with explicit recognition of evidentiary limits. Journal relationship: A related Clinical Focus Review presubmission proposal was submitted to Anesthesiology and assigned ALN-D-26-01469 after initial screening. This independent author manuscript is not an accepted manuscript or journal publication, and it does not imply journal endorsement. Version 1.2 adds a paragraph on evaluating proposed safeguards, distinguishing process measures from clinical outcomes, improving exposure denominators, and assessing unintended consequences. This revision was author initiated and was not based on journal reviewers’ feedback.