Sunset Limited
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- Jul 29, 2019
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Warning: Using google translate.
Since my method is propofol, I read about it for a long time. I decided to do a detailed thread on CTB with propofol, thiopental and N. The method is similar for propofol, thiopental and N for the IV route. First of all, I warn you. This method is a really hard route if you are not a healthcare professional. It requires doing IV exercises for a long time.
Propofol, thiopental, N are all potent GABA-A receptor agonists. In an overdose, they first make you completely unconscious and stops breathing. Too high dose especially given in a short time can cause cardiovascular collapse. There are two main methods. Bolus and infusion.
BOLUS METHOD
Someone can inject themselves with 20-25cc of propofol or thiopental before knock down. With N maybe a little more. For the bolus method, I will make it the lower limit so 20 cc. A large vein in the arm is needed to push 20 cc of solution in 10 seconds. Of course, it could also be a vein in the foot or leg. Using syringes and needles is not a good idea. A needle thin enough to enter a vein in the arm will not provide the flow rate needed to push 20 cc in 10 seconds. A needle that can do it, will be thick to burst the vein. So, an injector and needle is not a reliable way to do this. When pushing the plunger of the syringe too strongly, the needle may pierce the vein. Managing this is not easy. It is therefore best to use a 22g cannula in a large vein. The 22g cannula is wide enough to push 20cc in 10 seconds, but narrow enough to prevent a flow rate that would burst the vessel. In a study with a 22g cannula, a healthcare professional pushed the plunger with all his might. The vein was still fine when the blue cannula blowed a few seconds later. So, the best route is a 22g cannula inserted into a large vein in the arm, an infusion set (have an injection port), and a syringe. Of course, the injection can also be made through the IV port of the cannula. Still, it's easier to administer the injection with the infusion set.
Thiopental: The best agent for bolus is thiopental. It is available in powder vials for injection. It offers the advantage of being able to dissolve it in the least possible amount of water. If 1 gram of thiopental dissolves in 3 cc of water (whether saline or dextrose), that means 5 grams of thiopental in 15 cc water. 15cc is small enough to push through a large vein in the arm in less than 10 seconds. However, the injection is likely to be painful. Lidocaine for IV injections can prevent or reduce pain. Before thiopental, IV 40 mg of lidocaine should be injected over 20-30 seconds. For the average person, the anesthesia induction dose of thiopental is 250 - 350 mg. 5 grams of thiopental is a huge dose and absolutely fatal to the average person. It is 10 times the anesthesia induction dose for a 100 kg person and is deadly enough. Especially with a quick bolus. It probably causes cardiovascular collapse within 1-2 minutes. This seems to be the ideal method with thiopental.
N: N can be fatal with a bolus dose but depends on how much N is in 20 cc. Assuming the N from D is 6.3 g/100 ml, 20 cc of solution contains 1260 mg of N. This may not be enough for CTB. So 2 x IV access and 2 x injectors is a better idea. That means 2520 mg in total, which is enough. Two infusion sets (have an IV port) can be connected to 2 x IV accesses to give simultaneous injection. Injection in 10 seconds with a rapid bolus. So the injection can be painful. As I explained for thiopental, IV lidocaine solves the problem. A reminder about N, if the bottle has been opened or has sediment in it, it is not suitable for IV use!
Propofol: The maximum dose that can be injected even with 2 x IV access is 400 mg with propofol because it comes as 1% form, so CTB is not guaranteed. 400mg is lethal enough for the average person, but it's not guaranteed. My personal opinion for the average person is 90% chance of success. The chance of success decreases with alcohol or drug addiction and high fat ratio. Even the average person without addiction may have a high natural tolerance of GABA receptors due to mutation. I do not recommend. The injection will be more painful than others. In some countries, such as in the country I live in, propofol is available in 2% form. This means a total of 800 mg with 2 x syringes. This is absolutely deadly, but finding the 2% form is really hard. Still in Russia and other countries Anestofol is available. It contains 50 mg/ml propofol and 50 mg/ml lidocaine. 20 cc of Anestofol contains 1000 mg propofol and 1000 mg lidocaine. This is fatal but still I don't have enough information about Anestofol.
INFUSION METHOD
This requires a drip infusion setup or an infusion pump. While infusion pumps are a good option for N and thiopental, they are expensive. The largest injector that can be used with the infusion pump is 60 cc. Remember that 10 cc drug will remain in the infusion set! Not a good option for propofol, unless you have the 2% form on hand. Since N from D contains 3150 mg of pentobarbital in 50 cc, it can be injected with an infusion pump. So is thiopental. Infusion pumps can push 20cc per minute, maybe some of them more. That's enough for thiopental and N.
I will not talk about how to set drip infusion or putting a cannula into the vein. There are lots of videos about them on youtube. I will just give some tips.
The most important problem with drip infusion is, that there is a small chance that the flow may stop. One of the most important reasons for this is the incorrect use of the air vent on the drip chamber. I marked the air vent on the drip chamber in the picture below. The air vent use is tied to container types. If it is collapsable or not.
Below is a screenshot of how to use it and is a good resource on drip infusion setup. There are enough videos on Youtube about drip infusion setup and cannulation.
It's a good idea to use 2 x IV access and 2 x IV containers to infuse N, propofol or thiopental. Because even if the flow stops completely in one container, it will continue in the other. Both IV containers should have enough drugs for CTB. For added assurance, 2 x infusion sets can be connected to an IV container and connected to IV access via dual lumen.
MY INFUSION METHOD WITH PROPOFOL
I will talk about my method with propofol. I would do the same for N and thiopental. I will use 2 x IV bags. Putting 2000mg of propofol in both. The drip infusion flow can sometimes stop for no apparent reason. Therefore, using multiple IV bags and IV lines increases the chance of success. I will use two infusion sets for an IV bag as in the photo .
I will connect the two infusion sets I mentioned above to an IV access. This requires a double lumen. You can see how it is connected in the picture below.
There will be two IV accesses, one on my left arm and one on the dorsum of my left hand. I will infuse 4000 mg of propofol with 2 x IV containers and a total of 4 x infusion sets connected to them. In a very low probability, even if the flow is completely stopped in 3 infusion lines, it is still enough for CTB to continue in one. I have simply explained how it looks in the photo below.
I will use IV bag as IV container. I have two 250 cc bags containing 0,9 saline because I could not find any empty ones. I'm going to empty them out, put 2000mg of propofol in each and infuse them as described above. Even if flow continues in only one infusion set, 2000 mg of propofol will enter the circulation. The highest possible flow rate from a drip infusion (assuming the bag is hung as high as possible and a 22g cannula is used) is 7-8 ml/min. This means an average of 150 mg/min propofol flow with 2 x IV accesses. This flow rate means loss of consciousness in 45 - 60 seconds, surgical depth of anesthesia and the onset of apnea in 90 - 120 seconds for an average person. When the flow continues at this rate, there is no chance for an average person to survive in 15 minutes.
To make this more concrete, I used stanpump pharmacokinetic simulation. The chart below is for a healthy 30 years old, 70 kg, 170 cm male. It is an infusion at a flow rate of 150 mg/min. The yellow line I have drawn is the target plasma concentration for anesthesia induction. Propofol causes apnea at this concentration. So stop breathing. Continued infusion maintains apnea. The red line is the point at which we can say that it is impossible for someone to protect the airway. There is no need to talk much about propofol infusion at a flow rate of 150 mg/ml. Absolutely fatal. Death within 10 minutes. This infusion doesn't just stop breathing. Fatal hemodynamic effects. Arterial vasodilation and profound hypotension. Cardiovascular collapse before 10 minutes is not surprising.
The image below shows the graph for 2000mg of propofol infused from just one IV access at a rate of 75mg/min. It is debatable whether it will cause apnea. Still enough for airway collapse and serious hemodynamic effects. According to information from an anesthesiologist's upper airway endoscopy dataset, there are patients who can protect their airway at plasma concentrations of up to 17 µg/ml. This is of course an extreme example as long as we can ignore it. According to the simulation, the flow rate provides a plasma concentration of more than 20 µg/ml for 12 minutes. Even if someone weighs 100 kg, the same amount of propofol is enough for airway collapse. If we add the hemodynamic effects of 2 grams of propofol entering the system, it is absolutely fatal. That is, even if the flow stops completely in one IV access, the other is enough.
We don't need a simulation for thiopental. Thiopental has a much longer half-life than propofol. So, at the same flow rate, thiopental is more lethal than propofol. N is the same.
All of this may seem rather complicated to a non-health professional. The only problem in this method is IV cannulation. It takes a while to exercise. Drip infusion setup is easy. It is enough to watch the videos and follow the instructions. There doesn't seem to be anything I missed. If I remember anything though, I'll add it.
Since my method is propofol, I read about it for a long time. I decided to do a detailed thread on CTB with propofol, thiopental and N. The method is similar for propofol, thiopental and N for the IV route. First of all, I warn you. This method is a really hard route if you are not a healthcare professional. It requires doing IV exercises for a long time.
Propofol, thiopental, N are all potent GABA-A receptor agonists. In an overdose, they first make you completely unconscious and stops breathing. Too high dose especially given in a short time can cause cardiovascular collapse. There are two main methods. Bolus and infusion.
BOLUS METHOD
Someone can inject themselves with 20-25cc of propofol or thiopental before knock down. With N maybe a little more. For the bolus method, I will make it the lower limit so 20 cc. A large vein in the arm is needed to push 20 cc of solution in 10 seconds. Of course, it could also be a vein in the foot or leg. Using syringes and needles is not a good idea. A needle thin enough to enter a vein in the arm will not provide the flow rate needed to push 20 cc in 10 seconds. A needle that can do it, will be thick to burst the vein. So, an injector and needle is not a reliable way to do this. When pushing the plunger of the syringe too strongly, the needle may pierce the vein. Managing this is not easy. It is therefore best to use a 22g cannula in a large vein. The 22g cannula is wide enough to push 20cc in 10 seconds, but narrow enough to prevent a flow rate that would burst the vessel. In a study with a 22g cannula, a healthcare professional pushed the plunger with all his might. The vein was still fine when the blue cannula blowed a few seconds later. So, the best route is a 22g cannula inserted into a large vein in the arm, an infusion set (have an injection port), and a syringe. Of course, the injection can also be made through the IV port of the cannula. Still, it's easier to administer the injection with the infusion set.
Thiopental: The best agent for bolus is thiopental. It is available in powder vials for injection. It offers the advantage of being able to dissolve it in the least possible amount of water. If 1 gram of thiopental dissolves in 3 cc of water (whether saline or dextrose), that means 5 grams of thiopental in 15 cc water. 15cc is small enough to push through a large vein in the arm in less than 10 seconds. However, the injection is likely to be painful. Lidocaine for IV injections can prevent or reduce pain. Before thiopental, IV 40 mg of lidocaine should be injected over 20-30 seconds. For the average person, the anesthesia induction dose of thiopental is 250 - 350 mg. 5 grams of thiopental is a huge dose and absolutely fatal to the average person. It is 10 times the anesthesia induction dose for a 100 kg person and is deadly enough. Especially with a quick bolus. It probably causes cardiovascular collapse within 1-2 minutes. This seems to be the ideal method with thiopental.
N: N can be fatal with a bolus dose but depends on how much N is in 20 cc. Assuming the N from D is 6.3 g/100 ml, 20 cc of solution contains 1260 mg of N. This may not be enough for CTB. So 2 x IV access and 2 x injectors is a better idea. That means 2520 mg in total, which is enough. Two infusion sets (have an IV port) can be connected to 2 x IV accesses to give simultaneous injection. Injection in 10 seconds with a rapid bolus. So the injection can be painful. As I explained for thiopental, IV lidocaine solves the problem. A reminder about N, if the bottle has been opened or has sediment in it, it is not suitable for IV use!
Propofol: The maximum dose that can be injected even with 2 x IV access is 400 mg with propofol because it comes as 1% form, so CTB is not guaranteed. 400mg is lethal enough for the average person, but it's not guaranteed. My personal opinion for the average person is 90% chance of success. The chance of success decreases with alcohol or drug addiction and high fat ratio. Even the average person without addiction may have a high natural tolerance of GABA receptors due to mutation. I do not recommend. The injection will be more painful than others. In some countries, such as in the country I live in, propofol is available in 2% form. This means a total of 800 mg with 2 x syringes. This is absolutely deadly, but finding the 2% form is really hard. Still in Russia and other countries Anestofol is available. It contains 50 mg/ml propofol and 50 mg/ml lidocaine. 20 cc of Anestofol contains 1000 mg propofol and 1000 mg lidocaine. This is fatal but still I don't have enough information about Anestofol.
INFUSION METHOD
This requires a drip infusion setup or an infusion pump. While infusion pumps are a good option for N and thiopental, they are expensive. The largest injector that can be used with the infusion pump is 60 cc. Remember that 10 cc drug will remain in the infusion set! Not a good option for propofol, unless you have the 2% form on hand. Since N from D contains 3150 mg of pentobarbital in 50 cc, it can be injected with an infusion pump. So is thiopental. Infusion pumps can push 20cc per minute, maybe some of them more. That's enough for thiopental and N.
I will not talk about how to set drip infusion or putting a cannula into the vein. There are lots of videos about them on youtube. I will just give some tips.
The most important problem with drip infusion is, that there is a small chance that the flow may stop. One of the most important reasons for this is the incorrect use of the air vent on the drip chamber. I marked the air vent on the drip chamber in the picture below. The air vent use is tied to container types. If it is collapsable or not.
Below is a screenshot of how to use it and is a good resource on drip infusion setup. There are enough videos on Youtube about drip infusion setup and cannulation.
It's a good idea to use 2 x IV access and 2 x IV containers to infuse N, propofol or thiopental. Because even if the flow stops completely in one container, it will continue in the other. Both IV containers should have enough drugs for CTB. For added assurance, 2 x infusion sets can be connected to an IV container and connected to IV access via dual lumen.
MY INFUSION METHOD WITH PROPOFOL
I will talk about my method with propofol. I would do the same for N and thiopental. I will use 2 x IV bags. Putting 2000mg of propofol in both. The drip infusion flow can sometimes stop for no apparent reason. Therefore, using multiple IV bags and IV lines increases the chance of success. I will use two infusion sets for an IV bag as in the photo .
I will connect the two infusion sets I mentioned above to an IV access. This requires a double lumen. You can see how it is connected in the picture below.
There will be two IV accesses, one on my left arm and one on the dorsum of my left hand. I will infuse 4000 mg of propofol with 2 x IV containers and a total of 4 x infusion sets connected to them. In a very low probability, even if the flow is completely stopped in 3 infusion lines, it is still enough for CTB to continue in one. I have simply explained how it looks in the photo below.
I will use IV bag as IV container. I have two 250 cc bags containing 0,9 saline because I could not find any empty ones. I'm going to empty them out, put 2000mg of propofol in each and infuse them as described above. Even if flow continues in only one infusion set, 2000 mg of propofol will enter the circulation. The highest possible flow rate from a drip infusion (assuming the bag is hung as high as possible and a 22g cannula is used) is 7-8 ml/min. This means an average of 150 mg/min propofol flow with 2 x IV accesses. This flow rate means loss of consciousness in 45 - 60 seconds, surgical depth of anesthesia and the onset of apnea in 90 - 120 seconds for an average person. When the flow continues at this rate, there is no chance for an average person to survive in 15 minutes.
To make this more concrete, I used stanpump pharmacokinetic simulation. The chart below is for a healthy 30 years old, 70 kg, 170 cm male. It is an infusion at a flow rate of 150 mg/min. The yellow line I have drawn is the target plasma concentration for anesthesia induction. Propofol causes apnea at this concentration. So stop breathing. Continued infusion maintains apnea. The red line is the point at which we can say that it is impossible for someone to protect the airway. There is no need to talk much about propofol infusion at a flow rate of 150 mg/ml. Absolutely fatal. Death within 10 minutes. This infusion doesn't just stop breathing. Fatal hemodynamic effects. Arterial vasodilation and profound hypotension. Cardiovascular collapse before 10 minutes is not surprising.
The image below shows the graph for 2000mg of propofol infused from just one IV access at a rate of 75mg/min. It is debatable whether it will cause apnea. Still enough for airway collapse and serious hemodynamic effects. According to information from an anesthesiologist's upper airway endoscopy dataset, there are patients who can protect their airway at plasma concentrations of up to 17 µg/ml. This is of course an extreme example as long as we can ignore it. According to the simulation, the flow rate provides a plasma concentration of more than 20 µg/ml for 12 minutes. Even if someone weighs 100 kg, the same amount of propofol is enough for airway collapse. If we add the hemodynamic effects of 2 grams of propofol entering the system, it is absolutely fatal. That is, even if the flow stops completely in one IV access, the other is enough.
We don't need a simulation for thiopental. Thiopental has a much longer half-life than propofol. So, at the same flow rate, thiopental is more lethal than propofol. N is the same.
All of this may seem rather complicated to a non-health professional. The only problem in this method is IV cannulation. It takes a while to exercise. Drip infusion setup is easy. It is enough to watch the videos and follow the instructions. There doesn't seem to be anything I missed. If I remember anything though, I'll add it.
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