Paweł Radkowski, Agnieszka Kowalczyk, Michalina Figiel, Natalia Wolak

Thiopental on the margins of modern anesthesia. New directions in the drug’s applications

2025-07-23

Background. Thiopental is currently the only clinically used representative of barbiturates. It acts as an agonist of the -aminobutyric acid GABAA receptor. It has been employed as an intravenous anesthetic, an anticonvulsant, and a sedative agent in cases of elevated ICP, with properties including high lipid solubility and rapid blood-brain barrier penetration. Thiopental is characterized by zero-order kinetics and a fast prolongation of the context-sensitive half-life. Consequently, there is a risk of accumulation and prolonged sedation. Through the induction of hepatic enzymes, it may affect the metabolism of other drugs. Pentobarbital, the active metabolite of thiopental, may accumulate in patients with renal impairment and is considered a precipitating factor in porphyria.

Aim of the study. The aim of this study is to present key information about thiopental and to discuss the justification and prospects for its use in modern anesthesiology and intensive care. Both the advantages and disadvantages of thiopental are outlined, and the latest findings related to its clinical application are reviewed.

Materials and methods. This article is based on a literature review conducted using the PubMed, Google Scholar, and ScienceDirect databases, with combinations of keywords such as: “anesthesiology”, “intensive care”, “thiopental”, “pregnancy”, “refractory status epilepticus”, “electroconvulsive therapy”, “adverse effects”, “cancer”, and “porphyria”.

Results. The analysis of source reports indicates that the importance of thiopental in anesthesiology has declined in favor of the more modern intravenous anesthetic - propofol. Numerous adverse effects associated with thiopental require close patient monitoring. These include: local necrosis, porphyria, respiratory depression, and hypotension. Additionally, among barbiturates, it has the highest likelihood of triggering acute porphyria attacks. Although there are reports suggesting thiopental’s protective effects on neuronal cells, osteoblasts, and donor kidney tissue, current clinical evidence does not sufficiently support broader use of this agent. Nevertheless, there is an increasing interest in off-label applications, such as in the treatment of refractory status epilepticus, anesthesia during the clipping of unruptured intracranial aneurysms, and as an alternative sedative in the management of critically ill COVID-19 patients during the pandemic.

Conclusions. Thiopental was long regarded as a cornerstone of intravenous anesthesia; however, it is now used very rarely. Advances in pharmacology have restricted its use to selected specialized indications. Despite the discovery of its protective properties, thiopental has not regained a prominent role in everyday clinical practice. Its use is associated with a high risk of adverse effects, which further limits its popularity.

Keywords: intensive care units, intracranial pressure, thiopental, refractory status epilepticus.

© Farm Pol, 2024, 80(12): 871–879