Conventional lethal injection protocol[edit] Typically, three drugs are used in lethal injection.

Sodium thiopental is used to induce unconsciousness, pancuronium bromide (Pavulon) to cause muscle paralysis and respiratory arrest, and potassium chloride to stop the heart.[16] Sodium thiopental[edit] Main article: Sodium thiopental Lethal injection dosage: 25 grams Sodium thiopental (US trade name: Sodium Pentothal) is an ultra-short acting barbiturate, often used for anesthesia induction and for medically induced coma. The typical anesthesia induction dose is 0.35 grams. Loss of consciousness is induced within 3045 seconds at the typical dose, while a 5 gram dose (14 times the normal dose) is likely to induce unconsciousness in 10 seconds. A full medical dose of Thiopental reaches the brain in about 30 seconds. This induces an unconscious state. Within 5 to 20 minutes only 15% of the drug remains in the brain, with the rest redistributed to the rest of the body. The half-life of this drug is about 11.5 hours,[17] and the concentration in the brain remains at around 510% of the total dose during that time. When a 'mega-dose' is administered, as in state-sanctioned lethal injection, the concentration in the brain during the tail phase of the distribution remains higher than the peak concentration found in the induction dose for anesthesia. This is the reason why an ultra-short acting barbiturate, such as thiopental, can be used for long-term induction of medical coma. Historically, thiopental has been one of the most commonly used and studied drugs for the induction of coma. Protocols vary for how it is given, but the typical doses are anywhere from 500 mg up to 1.5 grams. It is likely that this data was used to develop the initial protocols for state-sanctioned lethal injection, according to which one gram of thiopental was used to induce the coma. Now, most states use 5 grams to be absolutely certain the dosage is effective. Barbiturates are the same class of drug used in medically assisted suicide. In euthanasia protocols, the typical dose of thiopental is 1.5 grams; the Dutch Euthanasia protocol indicates 1-1.5 grams or 2 grams in case of high barbiturate tolerance.[10] The dose used for capital punishment is therefore about 3 times more than the dose used in euthanasia. Pancuronium bromide (Pavulon)[edit] Main article: Pancuronium Lethal injection dosage: 100 milligrams Pancuronium bromide (Trade name: Pavulon): The related drug curare, like pancuronium, is a non-depolarizing muscle relaxant (a paralytic agent) that blocks the action of acetylcholine at the motor end-plate of the neuromuscular junction. Binding of acetylcholine to receptors on the end-plate causes depolarization and contraction of the muscle fiber; non-depolarizing neuromuscular blocking agents like pancuronium stop this binding from taking place. The typical dose for pancuronium bromide in capital punishment by lethal injection is 0.2 mg/kg and the duration of paralysis is around 4 to 8 hours. Paralysis of respiratory muscles will lead to death in a considerably shorter time. Other drugs in use are tubocurarine chloride and succinylcholine chloride. Pancuronium bromide is a derivative of the alkaloid malouetine from the plant Malouetia bequaertiana.[18] Potassium chloride[edit] Main article: Potassium chloride Lethal injection dosage: 100 mEq (milliequivalents) Potassium is an electrolyte, 98% of which is intracellular. The 2% remaining outside the cell has great implications for cells that generate action potentials. Doctors prescribe potassium for patients when there is insufficient potassium, called hypokalemia, in the blood. The potassium can be given orally, which is the safest

route; or it can be given intravenously, in which case there are strict rules and hospital protocols on the rate at which it is given. The usual intravenous dose is 1020 mEq per hour and it is given slowly since it takes time for the electrolyte to equilibrate into the cells. When used in state-sanctioned lethal injection, bolus potassium injection affects the electrical conduction of heart muscle. Elevated potassium, or hyperkalemia, causes the resting electrical potential of the heart muscle cells to be lower than normal (less negative). Without this negative resting potential, cardiac cells cannot repolarize (prepare for their next contraction). Depolarizing the muscle cell inhibits its ability to fire by reducing the available number of sodium channels (they are placed in an inactivated state). ECG changes include faster repolarization (peaked T-waves), PR interval prolongation, widening of the QRS, and eventual sine-wave formation and asystole. Cases of patients dying from hyperkalemia (usually secondary to renal failure) are well known in the medical community, where patients have been known to die very rapidly, having previously seemed to be normal. New lethal injection protocols[edit] The Ohio protocol, developed after the incomplete execution of Romell Broom, ensures the rapid and painless onset of anesthesia by only using sodium thiopental and eliminating the use of Pavulon and potassium as the second and third drugs, respectively. It also provides for a secondary fail-safe measure using intramuscular injection of midazolam and hydromorphone in the event intravenous administration of the sodium thiopental proves problematic.[19] Primary: Sodium thiopental, 5 grams, intravenous Secondary: Midazolam, 10 mg, intramuscular, and hydromorphone, 40 mg, intramuscular The brief for the U.S. courts written by accessories, the State of Ohio implies that they were unable to find any physicians willing to participate in development of protocols for executions by lethal injection, as this would be a violation of the Hippocratic Oath, and such physicians would be thrown out of the medical community and shunned for engaging in such deeds, even if they could not lawfully be stripped of their license.[19] On December 8, 2009, Kenneth Biros became the first person executed using Ohio's new single-drug execution protocol. He was pronounced dead at 11:47 a.m. EST, 10 minutes after receiving the injection. On September 10, 2010, Washington became the second state to use the single-drug Ohio protocol with the execution of Cal Coburn Brown.[20] Currently, seven states (Arizona, Georgia, Idaho, Ohio, South Dakota, Texas and Washington) have used the single-drug execution protocol. Four additional states (Arkansas, Kentucky, Louisiana and Missouri) have announced that they are switching to a single-drug protocol but, as of May 2013, have not executed anyone since switching protocols.[21] After sodium thiopental began being used in executions, Hospira, the only American company that made the drug, stopped manufacturing it due to its use in executions. [22] The subsequent nationwide shortage of sodium thiopental led states to seek for other drugs. Pentobarbital, a drug often used for animal euthanasia,[23] was used as part of a three drug cocktail for the first time on December 16, 2010, when John David Duty was executed in Oklahoma.[24] It was then used as the drug in a single drug execution for the first time on March 10, 2011, when Johnnie Baston was executed in Ohio.[25] Euthanasia protocol[edit] Euthanasia can be accomplished either through oral, intravenous, or intramuscular administration of drugs. In individuals who are incapable of swallowing lethal doses of medication, an intravenous route is preferred. The following is a Dutch protocol for parenteral (intravenous) administration to obtain euthanasia, with the old protocol

listed first and the new protocol listed second: First a coma is induced by intravenous administration of 1 g thiopental sodium (Nesdonal), if necessary, 1.5-2 g of the product in case of strong tolerance to barbiturates. Then 45 mg alcuronium chloride (Alloferin) or 18 mg pancuronium bromide (Pavulon) is injected. In order to ensure optimal availability, these agents are preferably given intravenously. However, there are substantial indications that they can also be injected intramuscularly. In severe hepatitis or cirrhosis of the liver, alcuronium is the agent of first choice.[10] Intravenous administration is the most reliable and rapid way to accomplish euthanasia and therefore can be safely recommended. A coma is first induced by intravenous administration of 20 mg/kg thiopental sodium in a small volume (10 ml physiological saline). Then a triple intravenous dose of a non-depolarizing neuromuscular muscle relaxant is given, such as 20 mg pancuronium bromide or 20 mg vecuronium bromide (Norcuron). The muscle relaxant should preferably be given intravenously, in order to ensure optimal availability. Only for pancuronium dibromide are there substantial indications that the agent may also be given intramuscularly in a dosage of 40 mg.[10] A euthanasia machine may allow an individual to perform the process alone. Constitutionality in the United States[edit] In 2006, the Supreme Court ruled in Hill v. McDonough that death-row inmates in the United States could challenge the constitutionality of states' lethal injection procedures through a federal civil rights lawsuit. Since then, numerous death-row inmates have brought such challenges in the lower courts, claiming that lethal injection as currently practiced violates the ban on "cruel and unusual punishment" found in the Eighth Amendment to the United States Constitution.[26][27] Lower courts evaluating these challenges have reached opposing conclusions. For example, courts have found that lethal injection as practiced in California,[28] Florida,[29] and Tennessee[30] is unconstitutional. On the other hand, courts have found that lethal injection as practiced in Missouri,[31] Arizona,[32] and Oklahoma[33] is constitutionally acceptable. On September 25, 2007, the United States Supreme Court agreed to hear a lethal injection challenge arising from Kentucky, Baze v. Rees.[34] In Baze, the Supreme Court addressed whether Kentucky's particular lethal injection procedure comports with the Eighth Amendment and will determine the proper legal standard by which lethal injection challenges in general should be judged, all in an effort to bring some uniformity to how these claims are handled by the lower courts.[35] Although uncertainty over whether executions in the United States would be put on hold during the period in which the United States Supreme Court considers the constitutionality of lethal injection initially arose after the court agreed to hear Baze,[36] no executions took place during the period between when the court agreed to hear the case and when its ruling was announced, with the exception of one lethal injection in Texas hours after the court made its announcement.[37] On April 16, 2008, the Supreme Court rejected Baze v. Rees thereby upholding Kentucky's method of lethal injection in a majority 72 decision.[38] Ruth Bader Ginsburg and David Souter dissented.[39] Several states immediately indicated plans to proceed with executions.