Recreational Nitrous Oxide Misuse: Anaesthetic Challenges and Perioperative Complications Including Airway Burns and Neurological Sequelae

Recreational use of nitrous oxide (N2O) ("hippy crack") has increased in recent years, with serious complications being reported, including airway cold injuries, neurological disease, and thrombotic events. This review highlights the perioperative implications of N2O misuse, with a focus on airway injury, neurological sequelae, and anaesthetic management. Cold burns from direct inhalation can compromise airway safety, while chronic use leads to functional vitamin B12 inactivation, resulting in subacute combined degeneration and peripheral neuropathy. In such patients, intraoperative use of N2O may exacerbate existing complications. Clinicians should maintain a high index of suspicion for N2O misuse, avoid its administration during anaesthesia, and consider early referral for neurological assessment and substance misuse support.