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 releases oxygen rapidly on contact with blood and tissue. Approximately 1 mL of 3% solution can generate 10 mL of oxygen. In a confined space or near injured vessels, this reaction can cause gas embolism, cardiovascular collapse, or neurologic injury. This narrative review brings together published operative reports, gas-embolism guidance, and safety warnings to explain how anatomy and irrigation technique create risk. It recommends avoiding peroxide in closed, deep, large, pressurized, poorly visualized, or potentially vascular operative spaces. Sudden deterioration during irrigation requires immediate cessation of exposure, oxygen, circulatory support, and prompt specialist assessment. Proposed hospital safeguards address solution selection, labeling, team communication, and authority to stop unsafe irrigation. The clinical priority is prevention: identify hazardous anatomy and use an appropriate irrigant that does not generate gas. Version 1.4, September 19, 2026, adds the discussion of fistulous tracts, poorly draining mediastinal spaces, and possible entry into the systemic circulation. It simplifies the prose and moves Scope and approach after the conclusion. This review uses public sources throughout. The hospital safeguards and team check are proposals for evaluation. Journal history: Anesthesiology declined the related presubmission proposal, ALN-D-26-01469, on September 17, 2026. This is an independent manuscript.