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Murray Trial - 4 October - Day 6 - Discussion

There were two bottles of loraz. one in the bathroom one on the nightstand
 
Soundmind;3503210 said:
I read the links you provided and I believe now it was Flumazenil THEN propofol . I will try to explain further everything Sophie said .

MJ at those high levels of lorazepam would have been in deep sedation, in fact studies confirm that at 10mg of lorazepm 93% of patients go in deep sedation , we r hearing talking about double that dose . it's not logical really to assume he could have been able to wake up on his own with the level of lorazepam found.
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so you think it’s not likely mj had developed this degree of tolerance?

but in this case i think it makes more sense to assume that murray gave the flumazenil first, and then gave propofol?


i think my first post was not really clear. let me try again:

the problem with flumazenil is, if you give it to a patient who had (repeatedly) received high lorazepam doses flumazenil can cause seizures. also, since flumazenil has a shorter half-life than lorazepam a patient can fall asleep again (resedation problem).

from romazicon (flumazenil) guideline:

http://www.drugs.com/pro/romazicon.html
Romazicon
...
Romazicon is known to precipitate withdrawal seizures in patients who are physically dependent on benzodiazepines, even if such dependence was established in a relatively few days of high-dose sedation in Intensive Care Unit (ICU) environments. The risk of either seizures or resedation in such cases is high and patients have experienced seizures before regaining consciousness. Romazicon should be used in such settings with extreme caution, since the use of flumazenil in this situation has not been studied and no information as to dose and rate of titration is available. Romazicon should be used in such patients only if the potential benefits of using the drug outweigh the risks of precipitated seizures. Physicians are directed to the scientific literature for the most current information in this area.
...
Patients who have received Romazicon for the reversal of benzodiazepine effects (after conscious sedation or general anesthesia) should be monitored for resedation, respiratory depression, or other residual benzodiazepine effects for an appropriate period (up to 120 minutes) based on the dose and duration of effect of the benzodiazepine employed. This is because Romazicon has not been established in patients as an effective treatment for hypoventilation due to benzodiazepine administration. In healthy male volunteers, Romazicon is capable of reversing benzodiazepine-induced depression of the ventilatory responses to hypercapnia and hypoxia after a benzodiazepine alone. However, such depression may recur because the ventilatory effects of typical doses of Romazicon (1 mg or less) may wear off before the effects of many benzodiazepines. The effects of Romazicon on ventilatory response following sedation with a benzodiazepine in combination with an opioid are inconsistent and have not been adequately studied. The availability of flumazenil does not diminish the need for prompt detection of hypoventilation and the ability to effectively intervene by establishing an airway and assisting ventilation.

Overdose cases should always be monitored for resedation until the patients are stable and resedation is unlikely.
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i think that’s why murray would have needed to wait until mj was starting to come out of the lorazepam sedation on his own before he could give him flumazenil: the risk of seizure or resedation was too high.

i suppose once a patient starts to wake up on his own, this would probably reduce both the risk of seizure and of resedation - at least it would make sense??

to get out of lorazepam sedation usually takes time. from what i understand it can take hours until a patient is fully alert. but when a patient receives flumazenil the patient wakes up within a few minutes, he is fully alert.

and flumazenil improves cognitive functions too according to studies:


this is probably the effect murray wanted:

mj should wake up smoothly and fast; it should not be a lengthy process, mj should not suffer severe cognitive problems after awakening, and he should not suffer from withdrawal symptoms during the daytime. it should feel similar to waking up from a propofol sedation.

there is indication flumazenil is good at treating (interdosage) withdrawal symptoms. flumazenil causes so called "precipitated withdrawal":


from what i understand, precipitated withdrawal means the patient goes through withdrawal within a few minutes and afterwards the patient feels well.

for this reason flumazenil could be used to get a patient completely off a benzodiazine in a very short time (with no lengthy withdrawal process), but because of the problem of seizure, the use of flumazenil in a so called "rapid detox" is controversial.

i found this website which explains how a rapid detox works; they do not do it for lorazepam using flumazenil because they think it’s too dangerous:
http://www.rapiddrugdetox.com/detox-facts--drugs/benzodiazepine-addiction.html

as i said above, i think this is one of the reasons why murray waited until mj was getting out of sedation by himself, before he gave the flumazenil, to reduce risk of seizure.


i think this could also be a reason why murray would give a propofol bolus before waking mj up with flumazenil:

a propofol bolus would cover the timeframe until the flumazenil effect has set in and until the patient is fully awake. mj would not suffer from side effects caused by flumazenil during wake-up, because he'd be under the influence of propofol during this timeframe.

here is explained how a rapid detox works under general anesthesia:

http://www.rapiddrugdetox.com/detox...from-demerol-meperidine-addiction--abuse.html
Rapid Anesthesia Demerol Detox
The RDD MethodSM for Demerol detoxification under anesthesia is a medical procedure that eliminates most of withdrawal symptoms. During the procedure the patient is given medication to relax and then put under light, general anesthesia for about an hour. Following the procedure, recovery begins under direct medical supervision. …
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the process described on this website is meant for people who are physically dependent and the idea is to get them completely off the painkiller or sedative. it’s not exactly the same thing what i think murray was doing during wake-up. i'm quoting from this site to give an idea what murray could have been doing to induce wake-up.

murray would use propofol as the anesthetic, and flumazenil would be the agent to counter the sedative.

as i said, i think murray wanted to make sure mj got a "smooth" wake-up experience, in spite of the flumazenil. it should be similar to waking up from propofol.

to wake up from propofol feels good according to what i read. it seems this is even a reason why some people get mentally addicted to propofol. they want to experience the euphoria connected to waking up from propofol and self-inject over and over again, dozens or even hundreds of times in one day.
(just for the record: this is NOT what mj was doing! i’m mentioning this because a patient getting out of propofol would not expect to be sleepy or unwell for hours, and he would also not expect to have a rough awakening, as can be the case when using flumazenil.)


re what happened on june 25:

sade anding said in her testimony she overheard mumbling and coughing. this indicates mj was alive and awake a few minutes before noon. but at TOD a huge amount of lorazepam was found in blood, and a large amount of propofol.

since propofol wears off after 10min, the (latest) propofol bolus must have been administered at shortly before noon. why would murray do this? mj should already have been up, instead he gave him propofol!

i think the reason why it was so late in the morning could have been that mj just wouldn’t wake up from the lorazepam: the lorazepam dose was so high that mj was still asleep from the lorazepam at shortly before noon.

murray had to wait and to wait until he could start the "wake-up" process using flumazenil and using propofol to cover the side effects of flumazenil during wake-up time.

i have two hypothetical scenarios what could have happened at the time sade anding called:

scenario 1:

mj eventually woke up. but murray had not expected it, he was busy on his phone.

when murray realized mj was getting out of sedation he went to mj's side. but mj was already moving, maybe he was already trying to get up.

murray quickly gave a propofol bolus to be able to give the flumazenil. but possibly because mj was moving around, murray gave the bolus too fast and mj died almost instanty.​


scenario 2:

mj did not wake up.

murray realized something was wrong while he was on the phone with sade anding. he went to mj's side and found out mj was still deeply sedated and he possibly had low oxygen levels (?)

murray decided he could not wait any longer and gave mj flumazenil.

in such a situation it would be considered an emergency, and the flumazenil was necessary to wake mj up from a too deep lorazepam sedation.

what murray should have done in such a case of an unintentional lorazepam overdose:
give one round of flumazenil, in the hope to wake mj up, and call 911 straight away to make sure mj would get intubated!

as the cardiologist from ucla has pointed out, to give flumazenil alone is not enough. in an emergency the patient needs to be monitored and intubated, even if flumazenil was administered and the patient could be awakened.

obviously, this is not what happened.

from sade anding's testimony we can conclude mj was awake at shortly before noon (mumbling, coughing). this means, if murray was using flumazenil to counter a lorazepam overdose the flumazenil was actually successful in waking the patient up.

but, murray did NOT call 911. instead he gave a propofol bolus!

why?

possibly because the scene was not ready; because mj should not see all the lorazepam and midazolam vials.
possibly because murray hoped he would be able to handle the situation on his own; that there was no need to get EMTs on board.

also, possibly murray hoped mj would later not recollect this incident: propofol can induce amnesia; this was also mentioned by the cardiologist from ucla.

patients receiving propofol often do not remember what happened during their treatment, even if they wake up during treatment.
the same is true for lorazepam to my knowledge.

after murray had given the flumazenil dose, mj must have woken up all at once; to get out of a deep lorazepam sedation using flumazenil can be rough. as i said above, in the worst case it can cause a seizure.

in such a case, mj was probably not just lying there peacefully, he was probably moving.

when murray tried to give him the propofol bolus (to win time, to try and cover-up what had just happened) he messed the bolus up.

murray gave the bolus too fast and mj died almost instantly.​


in this 2nd scenario murray would have given the propofol bolus after the flumazenil.
in the 1st scenario murray would have given the propofol bolus before the flumazenil (as i think murray could have done regularly).

given the large amount of lorazepam in blood at time of death, the 1st scenario would imply mj must have developed considerable(!) tolerance to lorazepam.

the 2nd scenario would imply that there had actually been TWO emergencies:
- one caused by a lorazepam overdose which murray was able to counter with flumazenil
- the second, fatal(!) emergency caused by a propofol bolus which murray administered AFTER he had given flumazenil



i hope it's clearer now what i'm trying to say?

sorry for this lengthy post. it’s not easy to explain.

- i don't know if it all makes sense. maybe some of the medics here could comment on my theory?
 
the flumazenil vial was empty . He gave him more than he admitted to.
so you think it’s not likely mj had developed this degree of tolerance?
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nope, based on my experience with my mother . She has been an addict for 40 years, and even she did not build such tolerance. Again did you see the cardiologist's face when Flangan asked her what she thought of him taking 20mg of lorazepam ?
but in this case i think it makes more sense to assume that murray gave the flumazenil first, and then gave propofol?
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completely agree.

I did understand what you wrote previoulsy , thanks for explaining again. Let's agree in order for MJ to be coughing under these high levels of lorazepam flumazenil was used first.

Based on the info you provided, using flumazenil the way he used it was also an act of negligence . Murray is a criminal , a sociopath , and 4 years in prison is not enough punishment. MJ was bound to die under his care .
 
Sophie, great research!

I'm not sure what makes me more angry...that Murray may have killed MJ trying to put him to sleep or the idea that he killed him trying to wake him up? They should be equally disturbing but it just seems worse that Michael was waking up to live another day and this doctor, chatting on the phone, cut his life short.

Murray must've thought saying he was out of the room and didn't know what happened would have been a better excuse for him versus being in the room, causing the arrest and THEN not being able to resusitate and save Michael. He must've figured being out of the room might create some doubt about what happened since no one else was a witness to what happened.

He's screwed either way. He's either the doctor who left the room and was negligent or the doctor who was negligent and killed Michael cuz he was distracted with his jumpoff on the phone...and then tried to cover it all up.
 
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