Nitrous oxide: a unique drug of continuing importance for anaesthesia

Early attempts to use nitrous oxide as a sole anaesthetic foundered because of its low potency. It has been used successfully as an adjunct to more potent anaesthetics, however, since 1868. By enabling reduced doses of more potent anaesthetics, nitrous oxide reduces the cost of anaesthesia and limits cardiorespiratory side effects. Nitrous oxide does increase the incidence of postoperative nausea and vomiting in cases where risk of this side effect is increased, but it seems likely that use of antiemetics prophylactically will negate this factor. Perhaps the greatest argument for the continued use of nitrous oxide is that it reduces the incidence of recall of intraoperative awareness. Reduced pharmacokinetic variability compared with other anaesthetics, especially intravenous agents, is likely to be a most important reason for this, although evidence is emerging that nitrous oxide also has pharmacodynamic advantages. There are specific situations in which nitrous oxide should not be used, but in the absence of these, its use can be favourably recommended.