Pharmacological profile of essential oils derived from Lavandula angustifolia and Melissa officinalis with anti-agitation properties: focus on ligand-gated channels

Natural Antioxidants: An Effective Strategy for the Treatment of Alzheimer's Disease at the Early Stage

The critical role of oxidative stress in Alzheimer's disease (AD) has been recognized by researchers recently, and natural antioxidants have been demonstrated to have anti-AD activity in animal models, such as Ginkgo biloba extract, soy isoflavones, lycopene, and so on. This paper summarized these natural antioxidants and points out that natural antioxidants always have multiple advantages which are help to deal with AD, such as clearing free radicals, regulating signal transduction, protecting mitochondrial function, and synaptic plasticity. Based on the available data, we have created a relatively complete pathway map of reactive oxygen species (ROS) and AD-related targets and concluded that oxidative stress caused by ROS is the core of AD pathogenesis. In the prospect, we introduced the concept of a combined therapeutic strategy, termed "Antioxidant-Promoting Synaptic Remodeling," highlighting the integration of antioxidant interventions with synaptic remodeling approaches as a novel avenue for therapeutic exploration.

The Effects of Essential Oils and Terpenes in Relation to Their Routes of Intake and Application

Essential oils have been used in multiple ways, i.e., inhaling, topically applying on the skin, and drinking. Thus, there are three major routes of intake or application involved: the olfactory system, the skin, and the gastro-intestinal system. Understanding these routes is important for clarifying the mechanisms of action of essential oils. Here we summarize the three systems involved, and the effects of essential oils and their constituents at the cellular and systems level. Many factors affect the rate of uptake of each chemical constituent included in essential oils. It is important to determine how much of each constituent is included in an essential oil and to use single chemical compounds to precisely test their effects. Studies have shown synergistic influences of the constituents, which affect the mechanisms of action of the essential oil constituents. For the skin and digestive system, the chemical components of essential oils can directly activate gamma aminobutyric acid (GABA) receptors and transient receptor potential channels (TRP) channels, whereas in the olfactory system, chemical components activate olfactory receptors. Here, GABA receptors and TRP channels could play a role, mostly when the signals are transferred to the olfactory bulb and the brain.

Effects of lavender on anxiety: A systematic review and meta-analysis

BACKGROUND

Anxiety is one of the uprising psychiatric disorders of the last decades and lavender administration has been traditionally suggested as a possible treatment. The objective of this review is to assess the efficacy of lavender, in any form and way of administration, on anxiety and anxiety-related conditions.

METHODS

The PRISMA guidelines were followed. Retrieved data were qualitatively and quantitatively synthesized. Randomized Controlled Trials (RCTs) and Non-Randomized Studies (NRSs) which investigated the efficacy of lavender, in any form and way of administration, on patients with anxiety, involved in anxiety-inducing settings or undergoing anxiety-inducing activities, compared to any type of control, without language restrictions, were identified through electronic database searches. Medline via PubMed, Scopus, Web of Science, Cochrane Library, EMBASE, and Google Scholar were systematically searched. All databases were screened up to November 2018. Risk of bias was assessed with the Cochrane risk-of-bias tool and the following domains were considered: randomization, allocation sequence concealment, blinding, incomplete outcome data, selective outcome reporting, and other biases.

RESULTS

65 RCTs (7993 participants) and 25 NRSs (1200 participants) were included in the qualitative synthesis and 37 RCTs (3964 participants) were included in the quantitative synthesis. Overall, the qualitative synthesis indicated that 54 RCTs and 17 NRSs reported at least a significant result in favor of lavender use for anxiety. The quantitative synthesis showed that lavender inhalation can significantly reduce anxiety levels measured with any validated scale (Hedges' g = -0.73 [95% CI -1.00 to -0.46], p < 0.00001, 1682 participants), as well as state anxiety (Spielberger's state-trait anxiety inventory (STAI)-State mean difference = -5.99 [95% CI -9.39 to -2.59], p < 0.001, 901 participants) and trait anxiety (STAI-Trait mean difference = -8.14 [95% CI -14.44 to -1.84], p < 0.05, 196 participants). Lavender inhalation did not show a significant effect in reducing systolic blood pressure as a physiological parameter of anxiety. A significant effect in diminishing anxiety levels was also found in favor of the use of oral Silexan® 80 mg/die for at least 6 weeks (Hamilton Anxiety Scale mean difference = -2.90 [95% CI -4.86 to -0.95], p = 0.004, 1173 participants; Zung Self-rating Anxiety Scale mean difference = -2.62 [95% CI -4.84 to -0.39], p < 0.05, 451 participants) or of the administration of massage with lavender oil (Hedges' g = -0.66 [95% CI -0.97 to -0.35], p < 0.0001, 448 participants).

DISCUSSION

The most important limitation of this review is the low average quality of available studies on the topic. The majority of included RCTs were characterized by a high overall risk of bias. Another limitation regards the heterogeneity of study designs, especially with regard to non-oral ways of administration. Overall, oral administration of lavender essential oil proves to be effective in the treatment of anxiety, whereas for inhalation there is only an indication of an effect of reasonable size, due to the heterogeneity of available studies. Lavender essential oil administered through massage appears effective, but available studies are not sufficient to determine whether the benefit is due to a specific effect of lavender. Further high-quality RCTs with more homogeneous study designs are needed to confirm these findings. Available information outlines a safe profile for lavender-based interventions, although more attention should be paid to the collection and reporting of safety data in future studies. Considering these findings, since treatments with lavender essential oil generally seem safe, and, in the case of inhalation, also simple and inexpensive, they are a therapeutic option which may be considered in some clinical contexts.

OTHER

The present systematic review was not funded and was registered in PROSPERO under the following number: CRD42019130126.

Herbal medicine for psychiatric disorders: Psychopharmacology and neuroscience-based nomenclature

Objectives: Herbs are frequently and concurrently used with prescribed drugs by patients worldwide. While clinical trials have found some herbs to be as useful as standard psychiatric drugs, most clinicians are unaware of their pharmacological mechanisms.Methods: We searched English language and other language literature with English abstracts listed in PubMed website, supplemented by additional through Google Scholar's free academic paper abstract website for publications on herbs, focussing on their clinical use in mental disorders, their neurobiology and their pharmacology.Results: A major reason for herbs remaining outside of mainstream psychiatry is that the terminology and concepts in herbal medicine are not familiar to psychiatrists in general. Many publications regarding the use of herbal medicine for psychiatric disorders are deficient in details regarding diagnosis, criteria for response and the neurobiology details compared with publications on standard psychotropic drugs. Nomenclature for herbal medicine is usually confusing and is not conducive to an easy understanding of their mode of action in psychiatric disorders.Conclusions: The recent neuroscience-based nomenclature (NbN) for psychotropics methodology would be a logical application to herbal medicine in facilitating a better understanding of the use of herbal medicine in psychiatry.

A randomised controlled trial of Lavender (Lavandula Angustifolia) and Lemon Balm (Melissa Officinalis) essential oils for the treatment of agitated behaviour in older people with and without dementia

OBJECTIVE

Lavender and Lemon Balm essential oils are popular in the management of older person agitation due to their ease of application, minimal side effects and low interaction with concurrent medications. This study addressed limitations in the literature to evaluate and compare effectiveness of Lavender and Lemon Balm essential oils on the agitated behaviour of older people with and without dementia living in residential aged care facilities [RACFs].

METHODS

Forty-nine nursing home residents with dementia (n=39) and without dementia (n=10) exhibiting agitation participated in this study. Participants were randomised to a counterbalanced, repeated measures design experiment that tests the treatments Lavender, Lemon Balm, and Placebo (Sunflower oil). Treatments were administered once daily for two-weeks followed by a two-week washout period before commencing the subsequent treatment. All participants trialed all three treatments over a 10-week period. Data were collected on the Neuropsychiatric Inventory (NPI) and Cohen-Mansfield Agitation Inventory (CMAI).

RESULTS

A significant difference was shown when essential oils effect were compared between the cognitive groups. Post hoc analysis reports Lemon Balm more effective in reducing NPI agitation (p = .04) and CMAI physical non-aggressive behaviour (PNAB) (p = .02) in residents without dementia. Lemon Balm less effective in reducing NPI irritability (p = 0.01) and Lavender more effective in reducing CMAI PNAB (p = 0.04) in dementia.

CONCLUSION

The findings support an opposing effect of Lemon Balm and Lavender in reducing agitated behaviour between the participant cognitive groups. There was no reduction in agitation with treatments when compared to placebo independent of cognitive groups.

Plants of the Genus Lavandula: From Farm to Pharmacy

The Lavandula genus, belonging to the Lamiaceae, includes 39 species, with nearly 400 registered cultivars. Lavandula are worldwide plants that occur over the Mediterranean, Europe, North Africa, southwest Asia to southeast India. Lavandula plants have been used since ancient time to flavor and preserved food, to treat diseases including wound healing, sedative, antispasmodic, microbial and viral infections. Numerous researches have described the chemical composition and the primary components of lavender oils are the monoterpenoids (linalool, linalyl acetate, 1,8-cineole, β-ocimene, terpinen-4-ol, and camphor), sesquiterpenoids (β-caryophyllene and nerolidol) and other terpenoid compounds (e.g., perillyl alcohol). The high concentrations of linalyl acetate make them attractive in perfumery, flavoring, cosmetics and soap industries. Currently, data on the antimicrobial activity of lavender plants have been scientifically confirmed. Indeed, lavender essential oils possess wide spectra of biological activities such as antispasmodic, carminative, analgesic, sedative, hypotensive, antiseptic, antimicrobial, antifungal, antidiuretic and general tonic action. In addition, clinical studies support their uses as treatment of health conditions. However, further clinical studies are necessary to define the magnitude of the efficacy, mechanisms of action, optimal doses, long-term safety, and, potential side effects of lavender plants.

A randomised double-blind placebo-controlled pilot trial of a combined extract of sage, rosemary and melissa, traditional herbal medicines, on the enhancement of memory in normal healthy subjects, including influence of age

OBJECTIVE

To evaluate for the first time the effects of a combination of sage, rosemary and melissa (Salvia officinalis L., Rosmarinus officinalis L. and Melissa officinalis L.; SRM), traditional European medicines, on verbal recall in normal healthy subjects. To devise a suitable study design for assessing the clinical efficacy of traditional herbal medicines for memory and brain function.

METHODS

Forty-four normal healthy subjects (mean age 61 ± 9.26y SD; m/f 6/38) participated in this study. A double-blind, randomised, placebo-controlled pilot study was performed with subjects randomised into an active and placebo group. The study consisted of a single 2-week term ethanol extract of SRM that was chemically-characterised using high resolution LC-UV-MS/MS analysis. Immediate and delayed word recall were used to assess memory after taking SRM or placebo (ethanol extract of Myrrhis odorata (L.) Scop.). In addition analysis was performed with subjects divided into younger and older subgroups (≤ 62 years mean age n = 26: SRM n = 10, Placebo n = 16; ≥ 63 years n = 19: SRM n = 13, Placebo n = 6).

RESULTS

Overall there were no significant differences between treatment and placebo change from baseline for immediate or delayed word recall. However subgroup analysis showed significant improvements to delayed word recall in the under 63 year age group (p < 0.0123) with Cohen's effect size d = 0.92. No adverse effects were observed.

CONCLUSION

This pilot study indicates that an oral preparation of SRM at the selected dose and for the period of administration is more effective than a placebo in supported verbal episodic memory in healthy subjects under 63 years of age. Short- and long- term supplementation with SRM extract merits more robust investigation as an adjunctive treatment for patients with Alzheimer's disease and in the general ageing population. The study design proved a simple cost effective trial protocol to test the efficacy of herbal medicines on verbal episodic memory, with future studies including broader cognitive assessment.

Modulation of T-type Ca2+ channels by Lavender and Rosemary extracts

Medicinal plants represent a significant reservoir of unexplored substances for early-stage drug discovery. Of interest, two flowering Mediterranean plants have been used for thousands of years for their beneficial effects on nervous disorders, including anxiety and mood. However, the therapeutic potential of these plants regarding their ability to target ion channels and neuronal excitability remains largely unknown. Towards this goal, we have investigated the ability of Lavender and Rosemary to modulate T-type calcium channels (TTCCs). TTCCs play important roles in neuronal excitability, neuroprotection, sensory processes and sleep. These channels are also involved in epilepsy and pain. Using the whole-cell patch-clamp technique, we have characterized how Lavender and Rosemary extracts, as well as their major active compounds Linalool and Rosmarinic acid, modulate the electrophysiological properties of recombinant TTCCs (CaV3.2) expressed in HEK-293T cells. Both the methanolic and essential oil extracts as well as the active compounds of these plants inhibit Cav3.2 current in a concentration-dependent manner. In addition, these products also induce a negative shift of the steady-state inactivation of CaV3.2 current with no change in the activation properties. Taken together, our findings reveal that TTCCs are a molecular target of the Lavender and Rosemary compounds, suggesting that inhibition of TTCCs could contribute to the anxiolytic and the neuroprotective effects of these plants.

Melissa officinalis L. - A review of its traditional uses, phytochemistry and pharmacology

ETHNOPHARMACOLOGICAL RELEVANCE

Melissa officinalis L. is a medicinal plant that has long been used in different ethno-medical systems especially in the European Traditional Medicine and the Iranian Traditional Medicine for the treatment of several diseases. It is also widely used as a vegetable and to add flavor to dishes

AIM OF THE REVIEW

This review aimed to provide a summary on the botanical characterization, traditional uses, phytochemistry, pharmacological activities, pharmacokinetics and toxicity of M. officinalis, and discusses research gaps and future opportunities for investigations on this plant.

MATERIALS AND METHODS

We extensively reviewed major unpublished old texts, and published and electronic literature on traditional medicines of different regions of the world to find traditional uses of M. officinalis. Electronic databases including Web of Science, PubMed, ScienceDirect, Google Scholar and Scopus were searched to find articles (published between 1956 and 2015) on pharmacology and phytochemistry of M. officinalis.

RESULTS

Traditional uses of M. officinalis have been recorded mostly in European countries, Mediterranean region and Middle East countries. Phytochemical investigations revealed that this plant contains volatile compounds, triterpenoids, phenolic acids and flavonoids. Crude extracts and pure compounds isolated from M. officinalis exhibited numerous pharmacological effects, from which only anxiolytic, antiviral and antispasmodic activities of this plant as well as its effects on mood, cognition and memory have been shown in clinical trials. AChE inhibitory activity, stimulation of the acetylcholine and GABAA receptors, as well as inhibition of matrix metallo proteinase-2 are the main mechanisms proposed for the widely discussed neurological effects of this plant.

CONCLUSIONS

Modern pharmacological studies have now validated many traditional uses of M. officinalis. The data reviewed here revealed that M. officinalis is a potential source for the treatment of a wide range of diseases especially anxiety and some other CNS disorders, though confirmatory trials are warranted to substantiate these effects in the clinical setting. Data regarding many aspects of this plant such as mechanisms of actions, pharmacokinetics, adverse effects of the extracts, potential interactions with standard-of-care medications and active compounds is still limited which call for additional studies particularly in humans.

Efficacy of orally administered Silexan in patients with anxiety-related restlessness and disturbed sleep--A randomized, placebo-controlled trial

The anxiolytic effect of Silexan, a patented active substance with an essential oil produced from Lavandula angustifolia flowers, was investigated in patients with anxiety-related restlessness and disturbed sleep. 170 out-patients with a diagnosis of restlessness (ICD-10 R45.1), a Hamilton Anxiety Scale (HAMA) total score ≥18 points and ≥2 points for HAMA items 'Tension' and 'Insomnia' participated in this randomized, double-blind trial and received 80mg Silexan or placebo once daily for 10 weeks. Patients with clinically important other psychiatric or neurological disorders potentially interfering with the assessment of treatment efficacy were excluded. Outcome variables were the HAMA as well as the Pittsburgh Sleep Quality Index (PSQI), the Zung Self-rating Anxiety Scale, a State Check inventory and the Clinical Global Impressions questionnaire. In the Silexan group the HAMA total score decreased from an average of 25.5±6.0 points at baseline to 13.7±7.0 points at treatment end, compared to a decrease from 26.5±6.1 to 16.9±9.8 for placebo, corresponding to decreases of 12.0 and 9.3 points (marginal means), respectively (group difference: p=0.03, ANCOVA with factor treatment and baseline value as covariate). In all outcome measures the treatment effect of Silexan was more pronounced than with placebo. According to the HAMA, 48.8% and 33.3% of the patients were responders (Silexan, placebo; reduction ≥50%; p=0.04) and 31.4% and 22.6% achieved remission (HAMA<10; p=0.20). 33.7% (Silexan) and 35.7% (placebo) of the participants reported adverse events. The study confirms the calming and anxiolytic efficacy of Silexan.

Can Ozone Alter the Terpenoid Composition and Membrane Integrity of in vitro Melissa officinalis Shoots?

Ozone affects volatile organic compounds that protect plants from biotic and abiotic stress. In vitro Melissa officinalis shoots were exposed to ozone (200 ppb, 3 h) in controlled environmental conditions: leaf pigments, membrane integrity and headspace composition were assayed during fumigation and after the recovery period (3 h from the beginning of the exposure, FBE). At the end of the exposure, no injury was observed in untreated and treated shoots, although an evident increase in lipid peroxidation was reported (+38.5 and +37.2% of TBARS levels in comparison with controls, respectively after 1 and 3 h FBE). The levels of total carotenoids significantly rose as a normal response mechanism to oxidative stress. SPME-GS-MS analysis showed that, as a consequence of the fumigation, the trends in non-terpenoid compounds increased after 1 and 3 h FBE. This suggests that the concentration and the duration of the treatment were enough to cause a breakdown of cells (as evidenced by increased TBARS levels) and involves an association between volatile products of the lipoxygenase pathway (LOX products) and membrane degradation.

GABA(A) receptor modulation by terpenoids from Sideritis extracts

SCOPE

GABAA receptors are modulated by Sideritis extracts. The aim of this study was to identify single substances from Sideritis extracts responsible for GABAA receptor modulation.

METHODS AND RESULTS

Single volatile substances identified by GC have been tested in two expression systems, Xenopus oocytes and human embryonic kidney cells. Some of these substances, especially carvacrol, were highly potent on GABAA receptors composed of α1β2 and α1β2γ2 subunits. All effects measured were independent from the presence of the γ2 subunit. As Sideritis extracts contain a high amount of terpenes, 13 terpenes with similar structure elements were tested in the same way. Following a prescreening on α1β2 GABAA receptors, a high-throughput method was used for identification of the most effective terpenoid substances on GABA-affinity of α1β2γ2 receptors expressed in transfected cell lines. Isopulegol, pinocarveol, verbenol, and myrtenol were the most potent modifiers of GABAA receptor function.

CONCLUSION

Comparing the chemical structures, the action of terpenes on GABAA receptors is most probably due to the presence of hydroxyl groups and a bicyclic character of the substances tested. We propose an allosteric modulation independent from the γ2 subunit and similar to the action of alcohols and anesthetics.

A randomized, controlled cross-over trial of dermally-applied lavender (Lavandula angustifolia) oil as a treatment of agitated behaviour in dementia

BACKGROUND

Lavender essential oil shows evidence of sedative properties in neurophysiological and animal studies but clinical trials of its effectiveness as a treatment of agitation in people with dementia have shown mixed results. Study methods have varied widely, however, making comparisons hazardous. To help remedy previous methodological shortcomings, we delivered high grade lavender oil in specified amounts to nursing home residents whose agitated behaviours were recorded objectively.

METHODS

64 nursing home residents with frequent physically agitated behaviours were entered into a randomized, single-blind cross-over trial of dermally-applied, neurophysiologically active, high purity 30% lavender oil versus an inactive control oil. A blinded observer counted the presence or absence of target behaviours and rated participants' predominant affect during each minute for 30 minutes prior to exposure and for 60 minutes afterwards.

RESULTS

Lavender oil did not prove superior to the control oil in reducing the frequency of physically agitated behaviours or in improving participants' affect.

CONCLUSIONS

Studies of essential oils are constrained by their variable formulations and uncertain pharmacokinetics and so optimal dosing and delivery regimens remain speculative. Notwithstanding this, topically delivered, high strength, pure lavender oil had no discernible effect on affect and behaviour in a well-defined clinical sample.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ACTRN 12609000569202).

Effect of lavender essential oil on LPS-stimulated inflammation

Lavender essential oil (LEO) is one the most favorite and widely used essential oils in aromatherapy. Many studies have demonstrated its functions in calming, assisting sleep, reducing pain and muscular spasms and its antiseptic function. To date, however, the mechanism of LEO on inflammation response is not well understood. In this study, we examined the effect of LEO on 5 μg/ml lipopolysaccharide (LPS) induced inflammation reaction in human monocyte THP-1 cells. We found treatment of 0.1% LEO significantly increased cell viability and inhibited the IL-1β and superoxide anion generation in LPS-stimulated THP-1 cells. Treatment with LEO down-regulated both LPS-induced protein levels of phospho-NF-κB and membrane Toll-like receptor 4. To determine whether the chaperone protein was involved in the reaction, we determined the levels of Heat Shock Protein 70 (HSP70). Our results showed that LEO increased HSP70 expression in LPS-stimulated THP-1 cells, suggesting that the LEO inhibited LPS-induced inflammatory effect might be associated with the expression of HSP70.

Epilepsy in the Renaissance: a survey of remedies from 16th and 17th century German herbals

ETHNOPHARMACOLOGICAL RELEVANCE

Before modern anticonvulsive drugs were developed people in central Europe used herbal remedies to treat epilepsy. Hundreds of different plants for this indication can be found in German herbals of the 16th and 17th centuries. Here we compile these plants and discuss their use from a pharmacological perspective.

MATERIALS AND METHODS

Nine of the most important European herbals of the 16th and 17th century including Bock (1577), Fuchs (1543), Mattioli (1590), Lonicerus (1660, 1770), Brunfels (1532), Zwinger (1696), and Tabernaemontanus (1591, 1678) were searched for terms related to epilepsy, and plants and recipes described for its treatment were documented. We then searched scientific literature for pharmacological evidence of their effectiveness. Additionally the overlapping of these remedies with those in De Materia Medica by the Greek physician Dioscorides was studied.

RESULTS

Two hundred twenty one plants were identified in the herbals to be used in the context of epilepsy. In vitro and/or in vivo pharmacological data somehow related to the indication epilepsy was found for less than 5% of these plants. Less than 7% of epilepsy remedies are in common with De Materia Medica.

CONCLUSIONS

Numerous plants were used to treat epilepsy in the 16th and 17th centuries. However, few of these plants have been investigated with respect to pharmacological activity on epilepsy related targets.

Medicinal plants and dementia therapy: herbal hopes for brain aging?

An escalating "epidemic" of diseases like Alzheimer's has not yet been met by effective symptomatic treatments or preventative strategies. Among a few current prescription drugs are cholinesterase inhibitors including galantamine, originating from the snowdrop. Research into ethnobotanicals for memory or cognition has burgeoned in recent years. Based on a multi-faceted review of medicinal plants or phytochemicals, including traditional uses, relevant bioactivities, psychological and clinical evidence on efficacy and safety, this overview focuses on those for which there is promising clinical trial evidence in people with dementia, together with at least one other of these lines of supporting evidence. With respect to cognitive function, such plants reviewed include sage, Ginkgo biloba, and complex mixtures of other traditional remedies. Behavioral and psychological symptoms of dementia (BPSD) challenge carers and lead to institutionalization. Symptoms can be alleviated by some plant species (e.g., lemon balm and lavender alleviate agitation in people with dementia; St John's wort treats depression in the normal population). The ultimate goal of disease prevention is considered from the perspective of limited epidemiological and clinical trial evidence to date. The potential value of numerous plant extracts or chemicals (e.g., curcumin) with neuroprotective but as yet no clinical data are reviewed. Given intense clinical need and carer concerns, which lead to exploration of such alternatives as herbal medicines, the following research priorities are indicated: investigating botanical agents which enhance cognition in populations with mild memory impairment or at earliest disease stages, and those for BPSD in people with dementia at more advanced stages; establishing an ongoing authoritative database on herbal medicine for dementia; and further epidemiological and follow up studies of promising phytopharmaceuticals or related nutraceuticals for disease prevention.

[Silexan and narcosis : case report and possibilities of preoperative and perioperative management]

The increased use of phytotherapeutic drugs means that anesthetists are more often confronted with these drugs. In this case report possible problems which can occur are demonstrated exemplified by silexan. Silexan is a phytotherapeutic anxiolytic which is used in anxiety disorders. Because of its potential mechanism of action via the neurotransmitter gamma-aminobutyric acid (GABA) receptors interactions with narcotic drugs are possible. The case of an 18-year-old girl who underwent an operation under general anesthesia while taking silexan as long-term medication is presented. The desired depth of narcosis could only be reached by inhalative induction with sevoflurane after unsuccessful induction attempts using intravenous propofol and thiopental. Possible explanations for this route and inhalative induction as a possible alternative are discussed.