Thiopental: A Propofol Alternative?

There have been widespread reports of propofol shortages over the last several years.  This obviously creates a certain amount of anxiety in the anesthesia world given that propofol has become a common component of anesthetic regimens in the U.S.  However, the impact is also being felt, perhaps even more so, in the world of pediatric sedation.  Given the favorable characteristics of propofol, many pediatric sedation services have shifted almost entirely to a propofol based sedation regimen.

Despite all the anxieties, most places are still able to get propofol.  However, the question does remain… What would you do if you could not get propofol?  Would we revert back to oral chloral hydrate?  What about the pentobarb regimens we were all happy to leave in the past?

Dexmedetomidine is a viable option in many cases but most people would agree it is no propofol, especially from the standpoint of cost and recovery.  Interestingly, Dr. Gordon Gale from St. Louis University, has been using another regimen for years that approximates what we see when using propofol.  He describes his experience below.

Na Thiopental for procedural sedation

By Dr. Gordon Gale

In the 1980’s, prior to propofol, there was a necessity to sedate children for radiation therapy. At that time many children diagnosed with acute lymphoblastic leukemia required prophylactic CNS radiation. In addition, children with Wilm’s tumor, retinoblastoma, and sarcomas also required radiation. Obviously, the children had to lie perfectly still for a short period of time (<5 minutes).

In my primary role as a pediatric oncologist, I started using Na thiopental to sedate young children for RT. We originally used chloral hydrate which was not only inefficient but largely ineffective and unreliable. I had some experience with pentobarbital, but was not satisfied with the prolonged sedation for short procedures and the unpleasant awakening for many children who had to be sedated daily for up to 6 weeks. Some children needed to be sedated twice a day. Prolonged sedations left little time for the children to drink and/or eat between sedations.

With thiopental, the rapid onset of sedation and short duration of effect seemed to make it an ideal agent for these short procedures.  Originally, I administered 2-4mg/kg as a bolus and then aliquots of 1-2 mg /kg every minute or so until the desired state of sleep.  Obviously, the children were closely monitored.  Some children required as much as 10-12 mg/kg total for the procedures.  I sedated 5- 10 children every year for anywhere from 10 to 30 days of radiation.  Thiopental was very effective and I found it to be safe.  Once I arrived at an adequate dose for a child, this dose remained amazingly consistent from day to day and there did not seem to be any tachyphylaxis.

Subsequently, I started to use thiopental along with fentanyl (2-3 µgm/kg) for painful procedures such as lumbar punctures and bone marrow aspirates. I found this combination to be effective and reasonably safe, although a low percentage of children became apneic.  I subsequently began using ketamine which I found to be more effective and safer.

In the eighties and nineties, I used Na Thiopental for some long procedures such as MRI and nuclear medicine scans. After the children were initially adequately sedated, I would routinely give 1-2mg/kg every 10 – 15 minutes. More recently, when I use thiopental for prolonged procedures, I give an initial bolus dose of 2- 4mg/kg and then a continuous infusion of 8mg/kg /hour and occasionally increase to 10mg/kg/hr if necessary.  The initial sedation is almost always accompanied by a big yawn and then sleep. The induction is actually much smoother than with propofol with less agitation (no burn). Anecdotally, my observation is that there is less hypotension as well (no firm data).

I am sorry that I do not have any scientific data but I have a lot of experience with Na Thiopental and find it to be very effective and safe for procedural sedation.

Gordon Gale M.D.

Professor of Pediatrics

Cardinal Glennon Children’s Medical Center

St Louis University

Other Shortages

It turns out that the current supply of Na Thiopental is not any more robust than that of the propofol.  However, these things are always changing.  It does seem that for certain select patients (severe egg allergy) or maybe even to bridge a temporary interruption in the supply of propofol, Na Thiopental might be an excellent alternative.

Thanks to Dr. Gale for sharing his experience with us on this innovative approach to quality sedation care for children.

4 thoughts on “Thiopental: A Propofol Alternative?

  1. Stuart Lieblich

    At this point in time why use thiopental over methohexital? Methohexital has such a long history of use in outpatient surgery, doesn’t accumulate and delay discharge as much as thiopental and is in good supply. It has been used in ambulatory oral and maxillofacial procedures since the 1960′s and has been shown to work well in conjunction with benzodiazepines and narcotics if needed.
    Side effects are some tachycardia and potential restlessness, but of course airway issues remain paramont.
    The typical protocol would be to start with a benzodiazepine such as midazolam, consider a dose of fentanyl or meperidine, followed by a bolus of methohexital of 0.5-1.0 mg/kg (preceded by a test dose). In outpatient oral surgical procedures that would permit administration of the local anesthetic without awareness and the continued sedative combination of the benzo and narcotic would then carry the case. Of course additional boluses of methohexital can be given as needed. The rapid onset and relatively rapid redistribution made it more ideal than thiopental, but not as good as we now find with propofol of course. Finally our patients are typically started on oxygen/ntirous oxide prior to starting the i.v. which helps with anxiety over the iv start as well as reducing syncope during that part.
    We still keep methohexital on hand for potential allergic patients to propofol, but since 2005 have used propofol as our primary agent. Its stability once reconstituted and lack of bacterial growth (due to high pH) has been shown over 6 weeks.
    Stuart Lieblich, D.M.D.
    Associate Clinical Professor, University of CT
    Department of Oral and Maxillofacial Surgery
    Private practice, Avon CT

  2. Robert C. Stough, M D

    “Back to the future?” I gladly embraced the arrival of propofol to the U.S. in the mid-1980′s and left pentothal in the past, along with such other wonderful drugs as chloroform and ether. We have made such progress in moving to propofol and to precedex/ketamine for example that I wonder why anybody would consider using barbiturates at all anymore. The doses mentioned for thiopental are anesthesia induction doses. Propofol, precedex, ketamine, even versed/fentanyl (since those two drugs have readily available antagonists) seem so intuitive that other regimens seem so counterintuitive, and with, I hope, the soon advent of fospropofol, we expect a safer form of propofol for sedation, why even consider a return to drugs that largely and rightly have been relegated to the dust bin of history?

  3. Nina Lubisch

    After 4 years of sedating children for radiation therapy for 5 minute intervals daily for several weeks of treatment, were given a small bolus of dexmedetomidine, doses ranged between 1.2mcg/kg-2mcg per kg, without a maintence drip, all completed the treatment plan and woke up after removing the child off of the table.

    One child who had multiple surgeries and had been maintained with propofol and various other agents, required a maintence drip and higer dose initial bolus.
    Ft Lauderdale, Pediatric Sedation Unit

  4. Christoph Ohngemach

    Propofol is still my drug of choice for pediatric sedation, but rectal thiopental is a nice alternative for the child with difficult IV access. It takes about 10 min for the child to fall asleep and it lasts long enough for the usual MRI of the brain without contrast.

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