When do you use Thiopental?

[samtron]

Can someone help me understand what are some "real world" uses for Thiopental (besides executions)?

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[geauxg8rs]

I use STP exclusively for celebs who need help with sleep at night yet somehow cannot afford propofol. Usually peeps that are opening acts or used to be in 80's hair bands yet blew all their cash on Aqua Net.

 

[Gern Blansten]

I use STP exclusively for celebs who need help with sleep at night yet somehow cannot afford propofol. Usually peeps that are opening acts or used to be in 80's hair bands yet blew all their cash on Aqua Net.

 

[Jeff05]

patients with egg allergies.
oh wait.

Can Diprivan be given to patients with an egg allergy since the formulation of "Diprivan" contains 1.2% egg yolk phospholipid?
Can Diprivan be given to patients with an egg allergy since the formulation of "Diprivan" contains 1.2% egg yolk phospholipid?

The soybean oil which Zeneca uses in 'Diprivan' undergoes a stringent purification process whereby all protein within the oil is removed. Patients who are allergic to eggs are generally allergic to egg protein or albumin, not lecithin (the egg phosphatides which are present in the ‘Diprivan' emulsion). A thorough search of the literature has revealed no evidence that lecithin is allergenic, or that it could act as a hapten, thus inducing allergenicity. The literature indicates that it is the glycoproteins found in food that are generally implicated as the allergenic component (Sampson and Cook, 1990).

The glycoproteins are characteristically water soluble, largely heat resistant and acid-stable, and commonly in the molecular weight range14-60 KDa. Sampson and Cook (1990) refer to four other papers where the specific allergenic components of egg and cow's milk have been isolated and characterised. They concluded that patients clinically allergic to egg and / or cows milk possess IgE and IgG antibodies to protein fractions in egg and cow's milk.

There is a recent case report by Bassett et. al. (1994) of an adverse allergic reaction to propofol in a patient with egg hypersensitivity. The authors state that 'propofol emulsion contains egg lecithin, a phosphatidylcholine found in egg yolk' and suggest that 'a history of egg allergy may have to be considered prior to administration of propofol'. This conclusion seems at odds with the studies quoted above. It seems more likely that the allergy in this case is due to either propofol or Intralipid, even though the incidence of allergy to either agent is very low. The incidence for propofol has been estimated to be 1 in 15 000 anaesthetics, irrespective of the mechanism involved and in 1 in 45 000 for immune reactions (Laxenaire et. al., 1992). The incidence with Intralipid is probably even lower. There have been very occasional reports of hypersensitivity following Intralipid eg., Kamath et.al., (1981) and Hiyama et. al. (1989). Hiyama et. al. (1989) using the RAST test demonstrated that an allergic response observed after Intralipid was probably due to soybean protein.

In conclusion, it does seem very likely that people who are allergic to eggs are allergic to the protein component. This could explain why 'Diprivan' is only very rarely a problem since the egg component in the emulsion is phospholipid. However, it is always advisable to ascertain the exact allergen in each individual case before deciding causality.

References

Bassett,C.W., Talusan-Canlas,E., Holtzin,L., Kumar,S., Chiaramonte,L.T.
An adverse reaction to propofol in a patient with egg hypersensitivity
Journal of Allergy and Clinical Immunology, 1994* 93 (1) Part 2: 242 Abs 476

Hiyama,D.T., Griggs,B., Mittman,R.J., et. al.
Hypersensitivity following lipid emulsion infusion in an adult patient
Journal of Parenteral and Enteral Nutrition, 1989, 13 (3) 318 - 320

Kamath,K.R., Berry,A.
Acute hypersensitivity reaction to Intralipid
New Engalnd Journal of Medicine, 1981, Feb 5* 360

Laxenaire,M.C., Maten-Bermejo,E., Moneret-Vautrin,D.A., Gueant,J.L.
Life-threatening anaphylactoid reactions to propofol ('Diprivan')
Anesthesiology, 1992, 77: 275 - 280

Sampson,H., Cook,S.K.
Food allergy and the potential allergenicity-antigenicity of microparticulated egg and cow's milk proteins
Journal of the Amercian College of Nutrition, 1990* 9 (4)* 410 – 417


one of my old attendings insisted on giving STP infusions instead of prop for peds endoscopies - on those kids with 1000 allergies (including "egg"). the GI attending who's area of expertise was on allergy was adamant that propofol is absolutely fine. needless to say the were in pacu forever.

also, since propofol is not technically approved for neonates - one of the peds attendings would use it for induction of the nicu potatoes.

 

[urge]

Pent, sux, tube.... there you go!

 

[Pilot Doc]

Can someone help me understand what are some "real world" uses for Thiopental (besides executions)?

The only place I've seen it used in 2 years in for stat GA c-sections. As I think about it, I'm not sure why this is (shame on me). I think the main issue is that Thiopental can be left out ready to administer far longer than propofol.

The one exception to the above is one idiosyncratic attending who refuses to use propofol.

 

[Gern Blansten]

Some insist on thiopental for c-sections due a study which showed lower apgar scores and neurobehavioral cores at 1 hour with propofol versus thiopental. Scores were similar at 4 hours. Most other studies have shown scores to be similar whether using propofol or thiopental(Chestnut 3rd edit. pg 435).

Some suggest that it is better for ECTs as well. I can't quote any data on that one though.

 

[Planktonmd]

Some suggest that it is better for ECTs as well. I can't quote any data on that one though.

Actually for ECT the agent of choice is Methohexital because it does not suppress seizure activity as Thiopental does.

The only place where Thiopental might still have some advantage is when you want to achieve burst suppression and maximal cerebral protection during neurosurgery but some might argue that Propofol might be as effective here as well.

 

[Monty Python]

The only place I've seen it used in 2 years in for stat GA c-sections. As I think about it, I'm not sure why this is (shame on me). I think the main issue is that Thiopental can be left out ready to administer far longer than propofol.

The one exception to the above is one idiosyncratic attending who refuses to use propofol.

Labor and delivery—

A study was conducted in 74 patients comparing the use of propofol with that of thiamylal-isoflurane for induction and maintenance of anesthesia during cesarean section. The study did not show any problems in the mothers or in the neonates with the use of propofol {55}. There was no difference between the neonates in the two groups in Apgar scores or the neurological and adaptive capacity scores (NACS) {55}. However, the manufacturer states that use of propofol is not recommended since data are insufficient to support its use in obstetrics, including cesarean section deliveries {01}.

http://www.drugs.com/mmx/propofol.html

 

[urge]

If propofol becomes a controlled drug I will probably switch to thiopental. That's about the only benefit propofol has.

 

[narcusprince]

We use stp for sedation when we put in our retrobulbar blocks.

 

[Fastrach]

Use it routinely as Plank pointed out to put pts in burst suppression during TAA repairs, as well as for aortic arch repairs under deep hypothermic circ arrest. Had an attending get really p.o.'d at me for using propofol once instead of STP since propofol was more expensive at that time, but now propofol's actually the cheaper of the 2 drugs at our institution...

 

[2ndyear]

We use stp for sedation when we put in our retrobulbar blocks.

Why? I am not saying it's wrong, just curious.

 

[narcusprince]

This is more anecdotal from my attending I work with. His theory is that with thiopental patients move less than with propofol, also thiopental is less of a cardiac depressant than propofol. Given our patient population older than 65 whom may be more sensative to that cardiac depressant effects. What do you use?

 

[Planktonmd]

This is more anecdotal from my attending I work with. His theory is that with thiopental patients move less than with propofol, also thiopental is less of a cardiac depressant than propofol. Given our patient population older than 65 whom may be more sensative to that cardiac depressant effects. What do you use?

I think he is wrong on both accounts.
Thiopental killed more soldiers in Vietnam than the Vietcong because of the hemodynamic depressant effect.
I am not sure what this means:
"His theory is that with thiopental patients move less than with propofol"
Because if you give enough of any induction agent patients will not move.

 

[periopdoc]

"Cardio-depressant" is a particularly bad term since it is very imprecise, but I think that the idea that thiopental (thiopentone) is "less of a cardio-depressant" probably stems from this 1985 article by Grounds et al The haemodynamic effects of intravenous induction. Comparison of the effects of thiopentone and propofol. This article has been cited in several texts that discuss the issue.

This article argues that at equipotent doses, propofol caused a greater decrease in arterial blood pressure, total peripheral resistance, and cardiac output than thiopentone. Their conclusion is "propofol depresses the cardiovascular system more than thiopentone."

More recent basic research seem to indicate that the difference in the direct effect of the two drugs on cardiac myocyte function is less significant than the Grounds article seems to suggest. Article 1 ...for an equivalent anesthetic effect, propofol depresses myocardial contractility less than thiopental. and Article 2 ...negative inotropic effects may explain in part the cardiovascular depression on induction of anesthesia with thiopental but not with propofol...

There likely is a greater decrease in chronotropy with propofol than with thiopental, of course that article also argues for a greater decrease in inotropy as well.

It seems that the current textbooks agree that a greater decrease in blood pressure from propofol at an equipotent dose to thiopental comes from a more profound effect on arterial and venous tone and thus a greater decrease in both preload and afterload from propofol.

This was tested on the 1993 ITE. For the purposes of written tests, I would say that equipotent propofol causes a greater decrease in blood pressure than thiopental. If pressed, I would say that it causes more depression of the cardiovascular system than thiopental. I would not select an answer that says there is a greater effect on actual cardiac function. It is hard to know if the examiners are going to test the "facts" that are in the text books or the "facts" that are in the literature.

In the real world I will state unequivocally that thiopental will result in a greater depression of blood pressure than propofol simply due to unfamiliarity with it among the current generation of anesthesiologists (myself included). Give me a 90-year-old dude with aortic stenosis and mitral regurg and I can provide a safe amount of propofol almost without looking at the syringe that I am injecting with. (in fact looking at the patient instead of the syringe is probably the safest way to administer propofol to this dude) I wouldn't have a f***ing clue what kind of thiopental dose to use.

- pod

 

[pgg]

Can someone help me understand what are some "real world" uses for Thiopental (besides executions)?

Well, this thread was well and truly complete at post #2, but ...

I use it for the occasional IV induction of a kid who already has an IV, simply because it stings less.

 

[Licoricestick]

We have a consultant who uses it for all the NOFs - she finds it harder to overdose the oldies with thio rather than propofol because the end point is clearer.
Most of the consultants in our department use it for ECT - mainly driven by the psychiatrists who prefer it to propofol (they claim the seizure quality is better.... I wonder if they just prefer their patients dopier for a bit longer after ECT).

In my beginnings of experimenting with different anaesthetic techniques I have done a few unmodified RSIs (yes - there are newbies out there doing thio, sux, tube!) and I actually prefer thio in those patients who I suspect may need a stack of induction drug (like the appendix that drinks and
uses pot - and won't admit to how much of either) - there ain't no one that a syringe of thio won't put to sleep.

 

[mcgreen]

If propofol becomes a controlled drug I will probably switch to thiopental. That's about the only benefit propofol has.

An attending I was working with would use STP in patients with a history of seizures in place of propofol. I have been using STP in patients with history of seizures when it is available, unfortunately in many institutions STP is hard to get and the amount wasted has to be documented.

 

[amyl]

we have an attending here who likes to use it all the time for the burns less reason. it is also super duper useful for the teaching point of letting the resident push the roc right after.... ;-)

 

[Bertelman]

we have an attending here who likes to use it all the time for the burns less reason. it is also super duper useful for the teaching point of letting the resident push the roc right after.... ;-)

Ahhh, just push it anyway. Most of mine don't even notice anymore.

 

[Gern Blansten]

we have an attending here who likes to use it all the time for the burns less reason. it is also super duper useful for the teaching point of letting the resident push the roc right after.... ;-)

Ahh yes, great for making cement.

 

[dhb]

I use it for the occasional IV induction of a kid who already has an IV, simply because it stings less.

Let's say it again: 21st century anesthesia

 

[pgg]

Let's say it again: 21st century anesthesia

What's your point? That propofol hurts, and that mixing it with lidocaine sometimes makes it hurt less? Something about measuring kallikrein as a surrogate end point for pain?

I've never seen a kid scream from thiopental going into a vein. I have seen that effect from propofol, with or without additives or the pseudo-bier-block lido pretreatment. The mechanism, while interesting, really isn't relevant - thiopental is a perfectly safe and acceptable drug for IV inductions, and in my experience, has worthwhile advantages over propofol in certain situations.

 

[dhb]

What's your point? That propofol hurts, and that mixing it with lidocaine sometimes makes it hurt less? Something about measuring kallikrein as a surrogate end point for pain?

I've never seen a kid scream from thiopental going into a vein. I have seen that effect from propofol, with or without additives or the pseudo-bier-block lido pretreatment. The mechanism, while interesting, really isn't relevant - thiopental is a perfectly safe and acceptable drug for IV inductions, and in my experience, has worthwhile advantages over propofol in certain situations.

I've never had a patient complain about propofol w lido except the couple of times i forgot the lido. I'm not arguing the use of STP, just that the sting is a bad excuse.

 

[amyl]

Ahhh, just push it anyway. Most of mine don't even notice anymore.

i agree push it anyways.... they only complain for a sec if at all. i have never had a pt in the pacu c/o the propofol burn.

 

[hoyden]

STP IS a controlled drug in many institutions and as such is less convenient. The other moment is a large dosing vial - splitting it up for several ones is too much hassle, IMHO.

 

[Mista Suprane]

STP IS a controlled drug in many institutions and as such is less convenient.

that's exactly why we use it much less where i am training.