Fatal errors in nitrous oxide delivery

Anaesthesia. 2007 Dec;62(12):1202-6. doi: 10.1111/j.1365-2044.2007.05193.x.


Nitrous oxide continues to be used frequently and the possibility of inadvertent fatal hypoxaemia resulting from technical errors with its administration still exists. A Medline analysis revealed only a few case reports over the last 30 years, and a closed claim analysis only reported 'claims involving oxygen supply lines' predating 1990. The aim of this study was to assess the frequency of nitrous oxide-related catastrophes during general anaesthesia in Germany, Austria, and Switzerland. As nitrous oxide-related anaesthesia casualties are rare but generally prosecuted, they almost invariably attract significant media attention. We scanned mass media archives from April 2004 until October 2006 for nitrous oxide-related disasters during general anaesthesia. This approach detected six incidents which were almost certainly nitrous oxide ventilation-related deaths. Searching non-scientific data bases demonstrates that severe incidents involving oxygen supply lines occurred after 1990, and may be much more frequent than previously thought.

Publication types

  • Case Reports
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Anesthesia, Inhalation / instrumentation
  • Anesthetics, Inhalation / administration & dosage
  • Anesthetics, Inhalation / poisoning*
  • Equipment Failure
  • Fatal Outcome
  • Female
  • Humans
  • Intraoperative Complications / chemically induced*
  • Male
  • Mass Media
  • Medication Errors*
  • Middle Aged
  • Nitrous Oxide / administration & dosage
  • Nitrous Oxide / poisoning*


  • Anesthetics, Inhalation
  • Nitrous Oxide