Carbamazepine Side Effects in Children and Adults

Summary: Most of the side effects associated with carbamazepine (Tegretol^®, USP, Geigy Pharmaceuticals) therapy are mild, transient, and reversible with an adjustment in dosage or rate of dosage increase. Direct reports to Geigy Pharmaceuticals for the period 1975 to 1986 totaled 371 hematologic, 396 dermatologic, and 156 hepatic and pancreatic occurrences out of more than 4 million patients treated. These include 27 cases of aplastic anemia and 10 of agranulocytosis. In a study of the incidence of side effects in 220 children below the age of 16 years who were receiving carbamazepine, drowsiness, loss of coordination, and vertigo were the most commonly observed side effects and were almost always transient and dose related. The findings of this study are comparable with those of other series assessing carbam-azepine-associated adverse reactions in children and adults. Overall, 30 to 50% of children and adults were reportedly free of side effects in these studies. Recommendations for carbamazepine therapy include education of patients and parents in the nature and likelihood of possible serious adverse reactions and routine monitoring to detect laboratory abnormalities.     

The effect of pentobarbital anaesthesia upon the extracellular fluid volume in the dog,studied by continuous infusion and single injection methods

The effect of pentobarbital anaesthesia on the volume and ionic composition of the extracellular space was studied in adult male mongrel dogs with permanent catheters in aorta and pulmonary artery. The extracellular fluid volume (Q ^ec ) was determined with: a) methods based on equilibration of the indicator throughoutQ ^ec by continuous infusion; b) methods based on the assumption that after a single injection of indicator the plasma indicator concentration equals extracellular indicator concentration as long as the log plasma indicator concentration-time curve is linear; c) a single injection method based on a closed flow system model with a single inflow and a single outflow orifice. The measurements were made before and 30 and 90 min after induction of anaesthesia. Thirty minutes after induction of anaesthesiaQ ^ec as determined with the method sub a, had decreased by about 10% and remained so during the following 60 min. The values ofQ ^ec as calculated by the method sub c fairly agreed withQ ^ec as determined with the method sub a and also showed a decrease ofQ ^ec during pentobarbital anaesthesia. The procedures sub b overestimatedQ ^ec and yielded a seemingly higherQ ^ec during anaesthesia, because the boundary conditions for these procedures do not apply. The haemoglobin concentration decreased by about 10% and the lactate concentration by about 50%. The phosphate concentration increased by about 25% while the other electrolyte concentrations (Na⁺, K⁺, Mg²⁺, Ca²⁺, Cl^–, HCO ₃ ^– ) did not change. A respiratory acidosis developed during the first 30 min and almost disappeared in the following 60 min. Possible explanations for the pentobarbital-induced concentration ofQ ^ec are discussed.     

Affinities of barbiturates for the GABA-receptor complex and A1 adenosine receptors: a possible explanation of their excitatory effects

Summary The effects of barbiturates on the GABA-receptor complex and the A₁ adenosine receptor were studied. At the GABA-receptor complex the barbiturates inhibited the binding of [³⁵S]t-butylbicyclophosphorothionate ([³⁵S]TBPT) and enhanced the binding of [³H]diazepam. Kinetic and saturation experiments showed that both effects were allosteric. Whereas all barbiturates caused complete inhibition of [³⁵S]TBPT binding, they showed varying degrees of maximal enhancement of [3H]diazepam binding; (±)methohexital was identified as the most efficacious compound for this enhancement. At the A₁ adenosine receptor all barbiturates inhibited the binding of [³H]N⁶-phenylisopropyladenosine ([³H]PIA) in a competitive manner. The comparison of the effects on [³H]diazepam and [³H]PIA binding showed that excitatory barbiturates interact preferentially with the A₁ adenosine receptor, and sedative/anaesthetic barbiturates with the GABA-receptor complex. It is speculated that the interaction with these two receptors might be the basis of the excitatory versus sedative/anaesthetic properties of barbiturates.Abbreviations GABA -aminobutyric acid - TBPT t-butylbicyclophosphorothionate 1073 - DMBB 5-(1,3-dimethyl)butyl-5-ethylbarbituric acid - MCB N-methyl-5-(1-cyclohexen-1-yl)-5-ethylbarbituric acid - MPPB N-methyl-5-phenyl-5-propylbarbituric acid - PIA N⁶-phenylisopropyladenosine Send offprint requests to M. J. Lohse at the above address     

Pentobarbital-induced drinking does not rely on a renal dipsogen

Injections of pentobarbital have been shown to produce drinking in both deprived and nondeprived rats and a number of other studies have shown that pentobarbital is a potent renin releasor. Since renin has been shown to be involved in thirst regulatory mechanisms and since the dipsogenic actions of other renin-releasing agents have been blocked by nephrectomy, we sought to determine whether or not pentobarbital-induced drinking relies on a renal dipsogen. Rats were either "sham" operated or nephrectomized under ether anesthesia. Five to six hours later, animals in each group were injected with either 9.5 mg/kg pentobarbital sodium or vehicle, and intakes were measured 60 minutes later. Statistical analysis of water intakes indicated that pentobarbital produced significant drinking in both control operated and in nephrectomized rats, and that the intakes in these two groups did not differ. These results indicate that pentobarbital-induced drinking is not secondary to increased plasma renin activity and may suggest the involvement of central mechanisms in the drinking response.     

Effects of thiopental on resistance vessels in cat skeletal muscle

Barbiturates are used clinically as anaesthetics and to reduce raised intracranial pressure. One side effect is hypotension, usually ascribed to a depression of cardiac contractility, while their effects on the resistance vessels are more controversial: both vasodilation and vasoconstriction have been described. This study analyzes the effects of thiopental on basal vascular tone in the cat skeletal muscle. We found that total resistance increased by almost 20% at low (50mol/l) and decreased down to about 50% of control at high (350 mol/l) plasma concentrations of thiopental. The vasoconstriction dominated in the large arterioles (i.d. >25 m) and the vasodilation in the small arterioles (i.d. <25 m). A dosedependent inhibition of myogenic vascular reactivity (here defined as the maximum resistance increase to a transient rise in transmural pressure) coincided with the vasodilation. Autoregulation of blood flow was depressed by thiopental. During vasoconstriction there was a net transcapillary fluid absorption and during vasodilation a net fluid filtration. The fluid movements could be ascribed to variations in capillary hydrostatic pressure. If applicable to the cerebral circulation these results suggest that thiopental at high plasma concentrations might induce, instead of reduce, interstitial brain oedema.     

A rapid method for detecting barbiturates in serum using EI-SIM

A simple and rapid method for analysis of barbiturates in serum has been developed. In order to extract and clean barbiturates in serum, a separation column packed with Extrelut and Florisil was used, and the eluate was directly analyzed by means of electron impact selected ion monitoring (EI-SIM). Selected ions used were base peak ions of 10 barbituartes, and the internal standard used was allobarbital or secobarbital. The calibration curves were linear over the range 0.5–5 ng. Extraction of replicate serum samples containing 20 g/1.5 ml and 5 g/1.5 ml resulted in a recovery of 87.2–105.2% and 81.6–104.6%, respectively, with the exception of phenobarbital, which was 151.9% and 172.1%, respectively. Secobarbital was also analyzed in the serum of 13 patients who had been given secobarbital intravenously. In 3 out of 10 cases, Secobarbital levels greater than 1 g/ml were detected more than 72 h after administration. This method seems to have possibilities for clinical use.Paper presented at the 2nd International Symposium ADVANCES IN LEGAL MEDICINE, Berlin, Germany, August 30–September 1, 1993     

Depletion of brain norepinephrine: differential influence on anxiolyic treatment effects

Rationale: Previous studies have demonstrated that anxiolytic-like anticonflict effects can be produced by either (1) acute administration of traditional anti-anxiety compounds (benzodiazepines or barbiturates) or (2) chronic administration of tricyclic (TCA) or monoamine oxidase inhibitor (MAOI) antidepressants. Objective: The present study determined the effects of noradrenergic neuronal depletion on these distinct anticonflict treatments. Methods: After 3 weeks of training in a repeated measures drink suppression conflict paradigm, water-restricted rats consumed 11–14 ml water/session (unpunished responding) and accepted 25–40 shocks/session (punished responding) during control (i.e., non-drug) 10-min test sessions. The noradrenergic neurotoxin DSP4 [N-(2-chloroethyl)-N-ethyl-2-bromobenzylamine hydrochloride; 65 mg/kg, IP] or its vehicle (saline; 1 ml/kg) was administered after 3 weeks of conflict testing. Conflict behavior was then evaluated for 8 weeks post-treatment. In separate groups of DSP4- and vehicle-pretreated subjects, the effects of acute administration (10-min pretreatment) of phenobarbital (5–40 mg/kg) or alprazolam (0.3–2.5 mg/kg) were determined. In a third experiment, the effects of chronic treatment with the TCA desipramine (DMI; 5 mg/kg, twice daily for 8 weeks) or the non-selective MAOI phenelzine (4.0 mg/kg, twice daily for 8 weeks) on conflict behavior were determined in additional groups of DSP4- or vehicle-pretreated subjects. Results: DSP4 treatment produced a modest yet statistically significant decrease in punished responding (i.e., anxiogenic-like effect) relative to vehicle controls. DSP4 pretreatment did not alter the anticonflict effects of acute alprazolam or phenobarbital treatment. In contrast, DSP4 treatment completely abolished the anticonflict effects produced by chronic DMI or chronic phenelzine treatment. Conclusions: Thus, noradrenergic neuronal integrity appears to be required for the anxiolytic-like effects of chronic antidepressant treatment, but not for the anxiolytic-like effects of acute treatment with barbiturates and benzodiazepines. Received: 6 August 1998/Final version: 16 October 1998     

Recent trends in barbiturate detection in medicolegal deaths

A study was undertaken of 51 cases where barbiturates were detected in post-mortem blood samples from 2000 to 2019 at Forensic Science South Australia, Adelaide, Australia. The cause of death was drug toxicity in only 27 (53%) (M:F = 19:8; age range 19-74yrs, mean 46yrs). In 17 cases, barbiturate toxicity was the primary cause of death, 14 due to pentobarbitone and 3 to phenobarbitone. All were suicides. Barbiturates were obtained by online purchase from overseas sources in 9 cases (33%), and through veterinary practice in 2 cases (7%). Drug toxicity deaths where barbiturates were detected rose from 1 in 2000–2004 to 11 in 2015–2019, and those where deaths were primarily due to barbiturate toxicity rose from 1 in 2000–2004 to 9 in 2015–2019. However, the mere detection of barbiturates in post mortem samples did not equate with illicit use, as 23 of the deaths (45%) were due to natural causes in individuals prescribed barbiturates for epilepsy. The usefulness of examining subset populations separate from accrued national data is also demonstrated in the significantly younger age of decedents in South Australia dying from deliberately administered barbiturates (46 yrs) compared to the national average of 57.9 yrs. The reasons for this difference will require further investigation as this may impact upon local suicide prevention strategies.     

Pentobarbital overdose: A case of contract killing

Suicides by pentobarbital overdose have increased since about 2012, which appear to be influenced by technical information on active euthanasia that has spread over the Internet. We encountered a pentobarbital poisoning case of a patient with amyotrophic lateral sclerosis. A caregiver found the patient unconscious immediately after two visitors left the room. The patient was immediately transferred to the emergency hospital but eventually declared dead. A fatal concentration of pentobarbital was detected in peripheral blood samples collected in the emergency hospital and during autopsy (53.8 μg/mL and 29.4 μg/mL, respectively). Because the ratios of pentobarbital concentrations between the gastric contents and peripheral blood were 35 and 29 in the hospital and autopsy samples, respectively, it is likely that pentobarbital was administered via the gastrostomy tube. The patient had contacted the visitors through social media. Although the patient had requested the doctor perform active euthanasia and expressed a desire to end their life on social media, nobody had noticed the plan to commit suicide.     

Intravenous anaesthetic agents

This article gives an overview of drugs frequently used for intravenous anaesthetic induction, as well as a brief overview of total intravenous anaesthesia. Physicochemical properties of intravenous anaesthetic drugs and their clinical and adverse effects are summarized. The article also discusses the historical context on the introduction of intravenous anaesthetic agents and highlights developments of novel agents.