Sodium thiopental, also known as thiopental sodium or thiopentone and sold under the brand name Pentothal, is a rapid-onset short-acting barbiturate general anesthetic. It is the thiobarbiturate analog of pentobarbital, and an analog of thiobarbital. Sodium thiopental is a therapeutic alternative on the World Health Organization's List of Essential Medicines. It was the first of three drugs administered during most lethal injections in the United States until the US division of Hospira objected and stopped manufacturing the drug for this purpose in 2011, and the European Union additionally banned the export of the drug for this purpose. Although thiopental abuse carries a dependency risk, its recreational use is rare. Sodium thiopental is well-known in popular culture, especially under the name "sodium pentothal," as a "truth serum," although its efficacy in this role is questioned.
Uses
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. 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. 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. 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. 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.
Medically-induced coma In addition to anesthesia induction, sodium thiopental was historically used to induce medical comas. 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. Reportedly, thiopental has been shown to be superior to pentobarbital in reducing intracranial pressure. 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.
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. 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.
Lethal injection
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