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{{short description|Form of execution involving injection of chemicals into the bloodstream}}
{{About||the 1993 album|Lethal Injection (album
{{Globalize|article|US|date=August 2023}}
{{Use mdy dates|date=March 2016}}
[[File:Map of US lethal injection usage.svg|thumb|250px|Usage of lethal injection for the death penalty by jurisdiction in the United States in
<br />'''With the death penalty'''
{{legend|#CC6633;|Jurisdiction uses only this method (15)}}
{{legend|#FF9900;|Jurisdiction uses this method primarily but has other methods (12)}}
'''Without the death penalty'''
{{legend|#7fff00;|Jurisdiction once used this method, but no longer does (8)}}
{{legend|#0048BA;|Jurisdiction once adopted this method, but never actually used it (4)}}
{{legend|#0099CC;|Jurisdiction has never adopted or used this method (11+)}}
]]<!--Please note that other methods' pages, namely firing squad, gas chamber, and electric chair, use the same map image and caption format. If you change the image or caption, please change the others too. -->
'''Lethal injection''' is the practice of injecting one or more drugs into a
First developed in the [[Capital punishment in the United States|United States]], it has become a legal means of execution in [[Capital punishment in China|Mainland China]], [[Capital punishment in Thailand|Thailand]] (since 2003), [[Capital punishment in Guatemala|Guatemala]], [[Capital punishment in Taiwan|Taiwan]], the [[Capital punishment in the Maldives|Maldives]], [[Capital punishment in Nigeria|Nigeria]], and [[Capital punishment in Vietnam|Vietnam]], though Guatemala abolished the death penalty in civil cases in 2017 and has not conducted an execution since 2000 and the Maldives has never carried out an execution since its independence. Although Taiwan permits lethal injection as an execution method, no executions have been carried out in this manner;<ref>{{cite web |url=https://www.deathpenaltyworldwide.org/country-search-post.cfm?country=Taiwan |title=The Death Penalty in Taiwan |access-date=2018-01-29 |url-status=live |archive-url=https://web.archive.org/web/20171118013613/http://www.deathpenaltyworldwide.org/country-search-post.cfm?country=Taiwan |archive-date=November 18, 2017 |df=mdy-all }}</ref> the same is true for Nigeria. Lethal injection was also used in the [[Capital punishment in the Philippines|Philippines]] until the country re-abolished the death penalty in 2006.<ref>{{cite web|url=http://www.capitalpunishmentuk.org/injection.html|title=Lethal injection|website=www.capitalpunishmentuk.org|access-date=2016-07-08|url-status=live|archive-url=https://web.archive.org/web/20160303202827/http://www.capitalpunishmentuk.org/injection.html|archive-date=March 3, 2016|df=mdy-all}}</ref>
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[[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 potassium levels in the blood are insufficient, called [[hypokalemia]]. The potassium can be given orally, which is the safest route; or it can be given intravenously, in which case strict rules and hospital protocols govern the rate at which it is given.
The usual intravenous dose of 10–20 mEq per hour 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 and ultimately leads to cardiac arrest. The potassium bolus delivered for lethal injection causes a rapid onset of elevated extracellular potassium, also known as [[hyperkalemia]], causing [[depolarization]] of the resting membrane potential of the heart muscle cells, particularly impacting the heart's pacemaker cells. However, potassium's effect on membrane potential is concentration dependent and ultimately occurs in two phases. Given the reference range for serum potassium is 3.5-5.5 mEq/L, concentrations up to 8 mEq/L shorten action potential duration and the refractory period due to an allosteric effect of potassium ions on potassium channels, leading to increased conduction velocity and subsequently quicker potassium efflux which contributes to quicker repolarization and the mentioned shortening of the refractory period.<ref name=":6">{{Cite journal |last1=Weiss |first1=James N. |last2=Qu |first2=Xhilin |last3=Shivkumar |first3=Kalyanam |date=March 2017 |title=The Electrophysiology of Hypo- and Hyperkalemia |url=https://www.ahajournals.org/doi/10.1161/CIRCEP.116.004667 |journal=Circulation: Arrhythmia and Electrophysiology |volume=10 |issue=3 |doi=10.1161/CIRCEP.116.004667 |pmid=28314851 |via=PubMed}}</ref><ref>{{Citation |last=Rastegar |first=Asghar |title=Serum Potassium |date=1990 |work=Clinical Methods: The History, Physical, and Laboratory Examinations |editor-last=Walker |editor-first=H. Kenneth |url=https://www.ncbi.nlm.nih.gov/books/NBK307/ |access-date=2024-08-16 |edition=3rd |place=Boston |publisher=Butterworths |isbn=978-0-409-90077-4 |pmid=21250149 |editor2-last=Hall |editor2-first=W. Dallas |editor3-last=Hurst |editor3-first=J. Willis}}</ref> At approximately 8 mEq/L and beyond, the shortened refractory period and increased resting membrane potential diminishes the quantity of voltage-gated sodium channels ready to contribute to rapid phase 0 depolarization due to the inactivation gate requiring further repolarization to open back up.<ref name=":6" /> At potassium concentrations beyond 14mEq/L, enough sodium channels remain inactivated to no longer generate an action potential, ultimately leading to no heart beat.<ref name=":6" /> Heart potassium levels after lethal injection can reach 160.0 mEq/L.<ref>{{Cite journal |last1=Bertol |first1=Elisabetta |last2=Politi |first2=Lucia |last3=Mari |first3=Francesco |date=January 2012 |title=Death by potassium chloride intravenous injection: evaluation of analytical detectability |url=https://pubmed.ncbi.nlm.nih.gov/21923800/ |journal=Journal of Forensic Sciences |volume=57 |issue=1 |pages=273–275 |doi=10.1111/j.1556-4029.2011.01907.x |issn=1556-4029 |pmid=21923800}}</ref>
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
====Sodium thiopental====
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===New lethal injection protocols===
The [[Ohio]] protocol, developed after the incomplete execution of [[Romell Broom]], aims to ensure 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,
* Primary: Sodium thiopental, 5 grams, intravenous
* Secondary: [[Midazolam]], 10 mg, intramuscular, [[
In 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 medical ethics, such as the [[Declaration of Geneva|Geneva Promise]], and such physicians would be thrown out of the medical community and [[shunning|shunned]] for engaging in such deeds, even if they could not lawfully be stripped of their license.<ref name="New Ohio Poisoning Protocol"/>
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Thiopental has a half-life around 11.5 hours (but the action of a single dose is terminated within a few minutes by redistribution of the drug from the brain to peripheral tissues) and the long-acting barbiturate phenobarbital has a half-life around 4–5 days. In contrast, the inhaled anesthetics have extremely short half-lives and allow the patient to wake up rapidly and predictably after surgery.
The average time to death once a lethal-injection protocol has been started is about 7–11 minutes.<ref>{{cite news |url=https://
====Dilution effect====
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{{more citations needed section|date=March 2017}}
Terminally ill patients in Oregon who have requested physician-assisted suicide have received lethal doses of barbiturates. The protocol has been highly effective in producing a so-called painless death, but the time required to cause death can be prolonged. Some patients have taken days to die, and a few patients have actually survived the process and have regained consciousness up to three days after taking the lethal dose.<ref>{{cite news |url=http://www.nbcnews.com/id/7090928 |archive-url=https://web.archive.org/web/20131224153944/http://www.nbcnews.com/id/7090928/ |url-status=dead |archive-date=December 24, 2013 |title=Patient survives doctor-assisted suicide attempt: Terminally ill cancer victim awakes from coma after 3 days |agency=Associated Press |date=March 4, 2005}}</ref> In a California legal proceeding addressing the issue of the lethal-injection cocktail being "cruel and unusual," state authorities said that the time to death following a single injection of a barbiturate could be as much as 45 minutes.<ref>{{cite news |url=https://articles.latimes.com/2006/feb/15/local/me-morales15/2 |work=Los Angeles Times |title=Change in Lethal Injections Ordered |first=Louis |last=Sahagun |date=February 15, 2006 |access-date=May 2, 2010 |url-status=dead |archive-url=https://web.archive.org/web/20110512054624/http://articles.latimes.com/2006/feb/15/local/me-morales15/2 |archive-date=May 12, 2011 |df=mdy-all }}</ref>
Barbiturate overdoses typically cause death by depression of the respiratory center, but the effect is variable.<ref>{{Citation |last1=Kang |first1=Michael |title=Benzodiazepine Toxicity |date=2023 |url=http://www.ncbi.nlm.nih.gov/books/NBK482238/ |work=StatPearls |access-date=2023-06-14 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=29489152 |last2=Galuska |first2=Michael A. |last3=Ghassemzadeh |first3=Sassan}}</ref> Some patients may have complete cessation of respiratory drive, whereas others may only have depression of respiratory function.<ref>{{Citation |last1=Drechsler |first1=Michael |title=Carbon Dioxide Narcosis |date=2023 |url=http://www.ncbi.nlm.nih.gov/books/NBK551620/ |work=StatPearls |access-date=2023-06-14 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=31869084 |last2=Morris |first2=Jason}}</ref> In addition, cardiac activity can last for a long time after cessation of respiration. Since death is pronounced after asystole and given that the expectation is for a rapid death in lethal injection, multiple drugs are required, specifically potassium chloride to stop the heart. In fact, in the case of [[Clarence Ray Allen]], a second dose of potassium chloride was required to attain.
===Stockpiling and sourcing of drugs===
A 2017 study found that four U.S. states that allow capital punishment are stockpiling lethal-injection drugs that are in short supply and may be needed for life-saving medical procedures elsewhere.<ref name="guardian-20apr2017">{{cite news|last1=Pilkington|first1=Ed|title=States are stockpiling lethal injection drugs which may be needed elsewhere to save lives|url=https://www.theguardian.com/world/2017/apr/20/states-stockpiling-lethal-injection-drugs-arkansas-execution|access-date=April 20, 2017|newspaper=[[The Guardian]]|date=April 20, 2017|url-status=live|archive-url=https://web.archive.org/web/20170420155309/https://www.theguardian.com/world/2017/apr/20/states-stockpiling-lethal-injection-drugs-arkansas-execution|archive-date=April 20, 2017|df=mdy-all}}</ref>
This stockpiling of lethal-injection drugs also extends to the federal level, with the source of such drugs being put into question. At least one alleged supplier, [[Absolute Standards]], is neither registered with the FDA,<ref>{{Cite news |last=Horton |first=Adrian |date=2024-04-08 |title=John Oliver on lethal injections: 'A protracted nightmare of suffering' |url=https://www.theguardian.com/tv-and-radio/2024/apr/08/john-oliver-lethal-injections-death-penalty |access-date=2024-04-12 |work=The Guardian |language=en-GB |issn=0261-3077}}</ref> nor registered as a controlled substances manufacturer with the DEA,<ref>{{Cite news |last=Allen |first=Jonathan |date=2020-07-14 |title=U.S. lawmakers ask four companies about role in government's execution drugs |url=https://www.reuters.com/article/idUSKCN24F2NY/ |work=Reuters}}</ref> and has seen investigations over its alleged involvement.
==See also==
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