E. C. Allison, P. Branford, P. Hughes

Sheffield Children's Hospital, UK


Healthcare is responsible for 4-5% of the UK’s carbon footprint.

Nitrous oxide is a potent greenhouse gas and accounts for 2% of the entire NHS carbon footprint.

In paediatric anaesthesia, nitrous oxide has long been used alongside volatile anaesthetic agents for inhalation inductions.  Its perceived value lies in its lack of odour and potential second gas effect leading to smoother and more rapid onset of anaesthesia.

Many anaesthetists no longer use nitrous oxide and elimination from clinical practice is one way to move towards NetZero carbon emissions by 2040.

The Nitrous Oxide project, shockingly found that 83-98% of procured nitrous oxide is wasted and lost to the environment.  This is through leakages in manifolds and pipelines, poor stock management and theft.


Ongoing clinical use of nitrous oxide in a tertiary paediatric hospital with concomitant high wastage and consequential unnecessary carbon emissions.

At our hospital, in one year, we noted at least 83% wastage, translating to >400,000 litres of nitrous oxide, 242 tonnes of C02e.

Strategy for change

Through education and departmental buy-in, to achieve decommissioning of the nitrous oxide manifold and pipelines.

To establish a leaner method of nitrous oxide provision for those anaesthetic situations where nitrous oxide has perceived value.

Measure of improvement

To establish the degree of usage of nitrous oxide in a tertiary paediatric hospital and compare with procurement to establish the extent of wastage.

To reduce procurement of nitrous oxide, decommission the manifold and measure the reduction in carbon emissions and cost.

Lessons learnt

Departmental buy-in is key to the successful decommissioning of a nitrous oxide manifold.

Importance of starting with an education piece to clinical and managerial staff and executive teams.

Importance of surveying colleague opinions about the value of nitrous oxide in their practice, their concerns and willingness to change.

Importance of creating a working party with key stakeholders, led by anaesthesia but to include an invested executive member, estates team, pharmacy, clinical engineering, sustainability and theatre leads.

Message for others

Nitrous oxide is a largely unnecessary agent in paediatric anaesthesia.  There are alternatives such as scents in face masks and patient distraction to ensure smooth, compliant inhalation inductions when they are required.

Many of our anaesthetists never use nitrous oxide, but we have created a leaner cylinder system that allows occasional use for those anaesthetists who still feel strongly about its benefits in certain patients.  This is the step-wise compromise until such time that the entire department feel able to stop using nitrous oxide.

To our knowledge, Sheffield Children’s Hospital is the first Children’s Hospital in the UK to decommission its nitrous oxide manifold and we hope others will follow.


  1. Anaesthetic nitrous oxide system loss mitigation and management. Alifia Chakera, Scottish Government. December 2022
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