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{{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 20212023
 
<br />'''With the death penalty'''
{{legend|#CC6633;|Jurisdiction uses only this method (15)}}
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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>
The usual intravenous dose is 10–20 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) and more depolarised than normal at rest. The sodium voltage-gated channels required for the rapid phase 0 depolarisation spike in the ventricular and atrial action potential can fire once, but will inactivate rapidly and become inexcitable due to the closure of a specific inactivation gate. This blockage would normally be removed from the pore when the membrane repolarises to more than −70mV however as there is a raised resting membrane potential this negative membrane potential cannot be reached and the inactivation of the sodium voltage-gated channels cannot be relieved. Thus there can be no subsequent action potentials generated within the affected sarcomere.<ref>{{cite book |last=Levick |first=J.R. |date=2010 |title=An Introduction to Cardiovascular Physiology |location=London, UK |publisher=Hodder Arnold |pages=37–56 }}</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 includevary depending on serum potassium concentrations and on the individual. Peaked T-waves signifying faster repolarization and potentially instances of early-repolarization and phase 2 re-entry (peakedBrugada, TShort QT, and Early-wavesRepolarization Syndromes), are evident in the first phase of hyperkalemia.<ref name=":6" /> This progresses into a broadening and lengthening of the P wave and PR interval, then eventually disappearance of the P prolongationwave, widening of the QRS complex, and finally, [[asystole]]. CasesThis ofprocess patientscan dyingoccur fromin hyperkalemiathe (usuallyspan secondaryof 30 to [[kidney60 failure]])seconds, arebut wellthere knownhave inbeen thecases medicalof community'botched' procedures, whereleading patientsto haveone beeninmate gasping for air for approximately known10 to die13 veryminutes.<ref>{{Cite rapidly,news having|date=2018-03-05 previously|title=Life seemedand toDeath beRow: normalHow the lethal injection kills |url=https://www.bbc.co.uk/bbcthree/article/cd49a818-5645-4a94-832e-d22860804779 |access-date=2024-08-16 |work=BBC Three |language=en-GB}}</ref>
 
====Sodium thiopental====
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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://articleswww.latimes.com/2006archives/la-xpm-2006-feb/-15/local/-me-morales15-story.html |title=Change in Lethal Injections Ordered: The state must execute Michael Morales with sedatives or ensure he cannot feel deadly drugs, U.S. judge rules |date=February 15, 2006 |first=Louis |last=Sahagun |newspaper=Los Angeles Times |url-status=live |archive-url=https://web.archive.org/web/20110321163620/http://articles.latimes.com/2006/feb/15/local/me-morales15 |archive-date=March 21, 2011 |df=mdy-all }}</ref> Because it takes only about 30 seconds for the thiopental to induce anesthesia, 30–45 seconds for the pancuronium to cause paralysis, and about 30 seconds for the potassium to stop the heart, death can theoretically be attained in as little as 90 seconds. Given that it takes time to administer the drug, time for the line to flush itself, time for the change of the drug being administered, and time to ensure that death has occurred, the whole procedure takes about 7–11 minutes. Procedural aspects in pronouncing death also contribute to delay, so the condemned is usually pronounced dead within 10–20 minutes of starting the drugs. Supporters of the death penalty say that a huge dose of thiopental, which is between 14 and 20 times the anesthetic-induction dose and which has the potential to induce a medical coma lasting 60 hours, could never wear off in only 10–20 minutes.
 
====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.
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===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'A protracted nightmare of suffering’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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