Lethal injection how much potassium

If condemned inmates are to be spared the intense suffering of conscious suffocation from pancuronium bromide, and the excruciating pain of potassium chloride burning through their veins, it is essential that they be properly anesthetized first. Sodium thiopental is the anesthetic administered at the start of the lethal injection execution to render the inmate unconscious before the other two drugs are injected.

The three-drug sequence used today in lethal injections was developed almost three decades ago and then, over the following two decades, was adopted by all but one of the death penalty states. Today, I would have just not been so specific in my drug language in the protocols, so that corrections officials could use the best agents of their time. Over the years, states have tinkered with certain relatively insignificant aspects of their death penalty procedures, for example, addressing how an inmate is brought into the execution chamber, whether to pay their executioners in cash or by check, how to accommodate media access, what type of catheter to use, and what time of day the execution will take place.

There are a few exceptions. Jeffrey Beard, secretary of the Pennsylvania Department of Corrections, told Human Rights Watch that one of the options under consideration is the use of a brain monitor to assess the effect of the anesthesia before the other two drugs are administered. In prior and ongoing litigation, states have not offered to change their drug protocols or methods of administration.

Mark Dershwitz, Reid v. Johnson , No. And those of us who routinely use pancuronium in our practice, take great pains to make sure that none of our patients are awake and paralyzed at the same time. In , when New Jersey's lethal injection statute was passed, a doctor at the NJDOC warned the NJDOC assistant commissioner that he had "concerns in regard to the chemical substance classes from which the lethal substances may be selected. Who knew what the future was going to bring? See also Affidavit of Dr.

Kevin Concannan, D. Beck, et al. In support of this contention, continuous or intermittent thiopental administration was formerly used for surgical procedures lasting many hours. In one study, 3. Depth and duration of thiopental anesthesia depends greatly upon dose and rate of administration, however, and bolus dosing results in significantly different pharmacokinetics and duration of efficacy than administration of the same quantity of drug at a lower rate [ 22 ].

In the modern practice of anesthesia, thiopental is used solely to induce a few moments of anesthesia prior to administering additional agents. Anesthesiologists are taught to administer a small test dose while assessing patient response and the need for additional doses [ 20 ].

Such stepwise administration and evaluation has been the practice from the first reports of thiopental usage in , due to the known potential for barbiturate-induced respiratory arrest [ 34 ]. It was early recognized that age, body composition, health status, anxiety, premedication, and history of substance abuse clearly influence response to thiopental, with some individuals showing marked resistance to standard doses [ 35 ] and others fatal sensitivity [ 25 ].

Thus the historical and modern clinical use of thiopental results from its cautious application to prevent respiratory arrest both in the typical patient and the abnormally susceptible. In consequence, there is almost no information about duration of anesthesia following large bolus doses of thiopental in unpremedicated patients, and there are few living anesthesiologists with clinical experience relevant to lethal injection protocols.

Unlike in clinical medicine, however, bolus injection of thiopental is regularly practiced in laboratory animals and veterinary medicine. Such dosages are conservative guidelines based on average responses of animals in experimental trials Table 1 , with the assumption that respiration and depth of anesthesia will be assessed in individual animals prior to onset of the procedure. In addition, thiopental is not recommended for painful procedures in animals.

Withholding or administering additional dosages would compensate for individual variation in response. Although species differences complicate pharmacological comparisons from animals to humans, animal studies are the basis for virtually all human drug trials. According to FDA guidelines, toxicity endpoints for drugs administered systemically to animals are typically assumed to scale well across species when doses are normalized to body surface area i.

Swine in particular are regarded as an excellent model of human cardiopulmonary and cerebrovascular physiology, with comparable size, body composition, and brain perfusion rates [ 40 ]. Comparing the HED for thiopental anesthesia in swine to lethal injection dosages, we conclude that at least some inmates at the lower end of the thiopental dose range might have experienced fleeting or no surgical anesthesia, while others at the higher end of the range might have received doses predicted to induce more prolonged anesthesia Table 1.

Such a prediction is impossible to evaluate, however, because any evidence of suffering would be masked by the effects of pancuronium.

Our study is necessarily limited in scope and interpretations. Given the secrecy surrounding lethal injections, we were able to analyze only a small fraction of the lethal injections in the US to date.

Indeed, the majority of executions actually take place in states such as Texas and Virginia, where the protocols and procedural problems are likely similar to the ones described, but where the states are unwilling to provide information [ 7 ].

Not only are available data limited, however, medical literature addressing the effects of these drugs at high doses and in combination is nonexistent, emphasizing the failure of lethal injection practitioners to design and evaluate rigorously a process that ensures reliable, painless death, even in animals.

In consequence, the adequacy of anesthesia and mechanism of death in the current lethal injection protocol remains conjecture. Despite such limitations, our analysis of data from more forthcoming states along with reports of problematic executions and judicial findings [ 41 ] together indicate that the protocol of lethal injection for execution is deeply flawed.

Technical difficulties are clearly responsible for some mishandled executions, such as Diaz's. Our analysis indicates that as used, thiopental might be insufficient both to maintain a surgical plane of anesthesia and to predictably induce death. Consequently, elimination of pancuronium or both pancuronium and potassium, as has been suggested in California [ 41 ], could result in situations in which inmates ultimately awaken.

With the growing recognition of flaws in the lethal injection protocol, 11 states have now suspended the death penalty, with nine of those seeking resolution of issues surrounding the process [ 42 ].

In California and Florida, commissions of experts have been charged with evaluating and refining lethal injection protocols. As deliberations begin, we suggest that the secrecy surrounding protocol design and implementation should be broken. The available data or lack of data should be made public and deliberations should be open and transparent. Competing Interests: JPS practices capital defense.

DAL has been a paid expert consultant in death penalty litigation. The other authors have no conflicts to disclose. Author contributions. All authors contributed to writing and editing the manuscript. Funding: The authors received no specific funding for this study. National Center for Biotechnology Information , U. PLoS Med. Published online Apr Clifford J Woolf, Academic Editor.

Author information Article notes Copyright and License information Disclaimer. E-mail: ude. Received Sep 27; Accepted Mar 2. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly credited.

See " Lethal Injection: Other Views " in volume 4, e This article has been cited by other articles in PMC. Abstract Background Lethal injection for execution was conceived as a comparatively humane alternative to electrocution or cyanide gas. Methods and Findings We analyzed data from two US states that release information on executions, North Carolina and California, as well as the published clinical, laboratory, and veterinary animal experience.

Conclusions We were able to analyze only a limited number of executions. Editors' Summary Background. Why Was This Study Done? What Did the Researchers Do and Find? What Do These Findings Mean? Additional Information. In a linked editorial the PLoS Medicine editors discuss this paper further and call for the abolition of the death penalty The Death Penalty Information Center is a rich resource on the death penalty both in the US and internationally Information on challenges to lethal injection in various states, including California and North Carolina, is available from the University of California, Berkeley School of Law Human Rights Watch monitors executions in the US Amnesty International campaigns against the death penalty A compendium of death penalty-related links are available from a pro-death-penalty site, the Clark County Prosecuting Attorney.

Introduction In the United States, lethal injection can be imposed in 37 states and by the federal government and military. Methods North Carolina lethal injection protocols were determined from Department of Corrections drug procurement records and testimony of prison personnel participating in the process.

Results Data from North Carolina Executions Three lethal injection protocols have been used in North Carolina from the first execution in to the most recent at the time of this writing in August Figure 1 A. Open in a separate window.

Figure 1. Lethal Injection Executions in North Carolina A Schematic depicting quantity and order of drug administration in the three protocols. Data from California Executions Executions in California provided a second insight into the methodologies and outcomes in lethal injections.

Figure 2. Lethal Injection Executions in California Depicted are duration of respiration and heart rate after initiation of the thiopental injection at time 0. Discussion Most US executions are beset by procedural problems that could lead to insufficient anesthesia in executions. References Denno D. When legislatures delegate death: The troubling paradox behind state uses of electrocution and lethal injection and what it says about us. Ohio State Law Journal. Accessed 16 March So long as they die: Lethal injection in the United States.

Virginia first used compounded pentobarbital obtained through the Texas Department of Criminal Justice in the execution of Alfredo Prieto on October 1, Ohio announced plans to obtain drugs from compounding pharmacies in October, In March , Mississippi announced plans to use pentobarbital from a compounding pharmacy.

Documents released in January , show that Louisiana had contacted a compounding pharmacy regarding execution drugs, but it is unclear whether the drugs were obtained there. Pennsylvania may have obtained drugs from a compounder, but has not used them. Colorado sent out inquiries to compounding pharmacies for lethal injection drugs, but all executions are on hold.

Alabama effective July , Mississippi effective April , and Oklahoma effective November all have laws that allow for use of nitrogen hypoxia. In federal executions, the method is lethal injection, which was the method used in all three of the federal executions in the modern era have been by lethal injection carried out in a federal facility in Indiana. Multiple people executed in recent years using midazolam have shown signs of pain—gasping, heaving against restraints, choking, and coughing.

In , Joseph Wood gasped and snorted for nearly two hours before he died; that same year, in Oklahoma, Clayton Lockett writhed on the execution table for 33 minutes before he died of a heart attack. Evidence of pulmonary edema has been presented to federal courts in a number of states, including Georgia, Arkansas, Missouri, Tennessee, and Ohio. Mike DeWine has put executions on hold due to concerns about pulmonary edema and a drug shortage.

The Supreme Court has not yet ruled on whether the pain associated with pulmonary edema violates the Eighth Amendment.