Sodium thiopental

Anesthesia

Sodium thiopental is an ultra-short-acting barbiturate and has been used commonly in the induction phase of general anesthesia. Its use has been largely replaced with that of propofol, but may retain some popularity as an induction agent for rapid-sequence induction and intubation, such as in obstetrics.[10] Following intravenous injection, the drug rapidly reaches the brain and causes unconsciousness within 30–45 seconds. At one minute, the drug attains a peak concentration of about 60% of the total dose in the brain. Thereafter, the drug distributes to the rest of the body, and in about 5–10 minutes the concentration in the brain is low enough that consciousness returns.

A normal dose of sodium thiopental (usually 4-6 mg/kg) given to a pregnant woman for operative delivery (caesarean section) rapidly makes her unconscious, but the baby in her uterus remains conscious. However, larger or repeated doses can depress the baby's consciousness.[11]

Sodium thiopental is not used to maintain anesthesia in surgical procedures because, in infusion, it displays zero-order elimination pharmacokinetics, leading to a long period before consciousness is regained. Instead, anesthesia is usually maintained with an inhaled anesthetic (gas) agent. Inhaled anesthetics are eliminated relatively quickly, so stopping the inhaled anesthetic allows rapid return of consciousness. Sodium thiopental would have to be given in large amounts to maintain unconsciousness during anaesthesia due to its rapid redistribution throughout the body (as it has a high volume of distribution). Since its half-life of 5.5 to 26 hours is quite long, consciousness would take a long time to return.[4]

In veterinary medicine, sodium thiopental is used to induce anesthesia in animals. Since it is redistributed to fat, certain lean breeds of dogs such as sighthounds have prolonged recoveries from sodium thiopental due to their lack of body fat and their lean body mass. Conversely, obese animals recover rapidly, but it takes much longer for the drug to be entirely removed (metabolized) from their bodies. Sodium thiopental is always administered intravenously, as it can be fairly irritating to tissue and is a vesicant; severe tissue necrosis and sloughing can occur if it is injected incorrectly into the tissue around a vein.[12]

Medically-induced coma

In addition to anesthesia induction, sodium thiopental was historically used to induce medical comas.[13] It has now been superseded by drugs such as propofol because their effects wear off more quickly than thiopental. Patients with brain swelling, causing elevation of intracranial pressure, either secondary to trauma or following surgery, may benefit from this drug. Sodium thiopental, and the barbiturate class of drugs, decrease neuronal activity thereby decreasing cerebral metabolic rate of oxygen consumption (CMRO2), thus decreasing the cerebrovascular response to carbon dioxide, which in turn decreases intracranial pressure. Patients with refractory elevated intracranial pressure (RICH) due to traumatic brain injury (TBI) may have improved long term outcome when barbiturate coma is added to their neurointensive care treatment.[14] Reportedly, thiopental has been shown to be superior to pentobarbital in reducing intracranial pressure.[15] This phenomenon is also called an inverse steal or Robin Hood effect as cerebral perfusion to all parts of the brain is reduced (due to the decreased cerebrovascular response to carbon dioxide) allowing optimal perfusion to ischaemic areas of the brain which have higher metabolic demands, since vessels supplying ischaemic areas of the brain would already be maximally dilated because of the metabolic demand.[16]

Euthanasia

Sodium thiopental is used intravenously for the purposes of euthanasia. In both Belgium and the Netherlands, where active euthanasia is allowed by law, the standard protocol recommends sodium thiopental as the ideal agent to induce coma, followed by pancuronium bromide to paralyze muscles and stop breathing.[17]

Intravenous administration is the most reliable and rapid way to accomplish euthanasia. Death is quick. A coma is first induced by intravenous administration of 20 mg/kg thiopental sodium (Nesdonal) in a small volume (10 mL physiological saline). Then, a triple dose of a non-depolarizing neuromuscular blocking drug is given, such as 20 mg pancuronium bromide (Pavulon) or 20 mg vecuronium bromide (Norcuron). The paralytic should be given intravenously to ensure optimal bioavailability but pancuronium bromide may be administered intramuscularly at an increased dosage level of 40 mg.[17]

Lethal injection

Along with pancuronium bromide and potassium chloride, thiopental is used in 34 US states to execute prisoners by lethal injection. A large dose is given to ensure rapid loss of consciousness. Although death usually occurs within ten minutes of the beginning of the injection process, some have been known to take longer.[18]

In December 2009, Ohio became the first state in the US to use a single dose of sodium thiopental for an execution, following the failed use of the standard three-drug cocktail during a prior execution, due to inability to locate suitable veins. Kenneth Biros was executed using the single-drug method.[19]

Washington became the second state in the US to use the single-dose sodium thiopental injections for executions. In September 2010, the execution of Cal Coburn Brown was the first in the state to use a single-dose, single-drug injection. His death was pronounced approximately one and a half minutes after the intravenous administration of five grams of the drug.[20]

After its use for the execution of Jeffrey Landrigan in the US, the United Kingdom introduced a ban on the export of sodium thiopental in December 2010,[21] after it was established that no European supplies to the US were being used for any other purpose.[22] The restrictions were based on "the European Union Torture Regulation (including licensing of drugs used in execution by lethal injection)".[23] From 21 December 2011, the EU extended trade restrictions to prevent the export of certain medicinal products for capital punishment, stating that "the Union disapproves of capital punishment in all circumstances and works towards its universal abolition".[24]

Truth serum

Thiopental is still used in some places as a truth serum to weaken the resolve of a subject and make the individual more compliant to pressure.[25] Barbiturates decrease both higher cortical brain function and inhibition. It is thought that because lying is a more involved process than telling the truth, suppression of the higher cortical functions may lead to the uncovering of the truth. The drug tends to make subjects verbose and cooperative with interrogators; however, the reliability of confessions made under thiopental is questionable.[26]

Psychiatry

Psychiatrists have used thiopental to desensitize patients with phobias[27] and to "facilitate the recall of painful repressed memories."[28] One psychiatrist who worked with thiopental is Jan Bastiaans, who used this procedure to help relieve trauma in surviving victims of the Holocaust.[29] Another notable psychiatrist using thiopental for the first time in the 1960s in psychoanalytic therapy setting - in a somewhat similar way to psycholytic psychotherapy - was the Hungarian-Australian psychiatrist Imre Zádor.[30] He administered thiopental to psychotherapy patients to reduce transferential resistance in cases of anorexia nervosa as well as to resolve unconscious blockages in other cases.