An otherwise healthy male infant was brought to the hospital because his mother suspected a superficial infection 5 days after the infant underwent an inguinal hernia repair. After being admitted to the pediatric unit for evaluation by his surgeon the next morning, an IV (venous infusion) of maintenance fluids was started. The infant immediately went into cardio-respiratory arrest and failed to respond to resuscitation efforts. Subsequently, air collections were found in both venous and arterial circulation, including the splenoportal system. The death was determined to be caused by air embolism. Air was introduced into the infant's system through the IV. No other precipitating event explains the pattern of autopsy findings. Venous air embolism may occur more often than is realized due to difficulty in diagnosis and the transient nature of clinical findings. It may not be identified at autopsy unless special care is taken to do so. Widely disseminated venous and arterial air collections in the thorax, abdomen, heart, and brain are the only radiographic or postmortem abnormalities apart from agonal pulmonary edema. The authors offer this quote from J.D. Gottleib et al. (1965): "There is no instance in which a needle is placed in the venous system when the hazard of air embolism does not exist." The same text notes that this is almost always the result of a therapeutic error or carelessness. 4 figures and 44 references