LETHAL EXECUTION USING FENTANYL . . . AN ANESTHESIOLOGIST’S OPINION

Lethal injection using fentanyl occurred for the first time in the death penalty execution of Carey Dean Moore in Nebraska August 14th, 2018.

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Per CBS News, “The Nebraska drug protocol called for an initial IV dose of diazepam, commonly known as Valium, to render the inmate unconscious, followed by the powerful synthetic opioid fentanyl, then cisatracurium besylate to induce paralysis and stop the inmate from breathing and potassium chloride to stop the heart.

Diazepam and cisatracurium also had never been used in executions before.”

From an anesthesiologist’s point of view:

  1. Valium (diazepam), an antianxiety drug, is seldom used in current surgical anesthesia practice, as it has been replaced by Versed (midazolam), which has a faster onset and causes less stinging on intravenous injection.
  2. Fentanyl, a powerful morphine-type narcotic, given in very high doses, brings on sedation, respiratory depression, and unconsciousness. The combination of Valium and high doses of fentanyl (typically 100 micrograms per kilogram) was the standard anesthetic used for open heart surgery in the 1980s. High doses of fentanyl can cause chest wall rigidity, which would add to any agonal respiratory efforts during a lethal injection, hence the necessity of a muscle relaxant (see below).
  3. Cisatracurium, a muscle relaxant or paralyzing drug, blocks all muscle movement and breathing. The paralyzing drug is used to both stop respiration and to eliminated any writhing and agonal movements during the dying movements.
  4. Potassium chloride, in high concentrations, causes the heart to fibrillate and cease beating.

Beginning in the 1970s, initial lethal injection recipes in the United States included 1) sodium thiopental (a barbiturate) to induce sleep, 2) pancuronium (a muscle relaxant) to paralyze the individual, and 3) potassium chloride to fibrillate the heart. In the 1970s-1990s, thiopental and pancuronium were commonly used anesthetic drugs. (In recent decades, propofol has replaced thiopental as the hypnotic of choice for general anesthesia for surgery, and the drugs rocuronium and vecuronium have replaced pancuronium as muscle relaxants for surgery.)

The European Union banned the export of thiopental for lethal injection in 2011, and a search for available alternate sedatives and intravenous anesthetics ensued. By 2016, more than twenty American and European pharmaceutical manufacturers had blocked the sale of their drugs for use in lethal injections, effectively making most FDA-approved unavailable for any potential lethal execution drug.1

This use of fentanyl, diazepam, and cisatracurium in Nebraska is the latest chapter in the recipe for lethal injection story. Stay tuned to see whether the manufacturers of these drugs choose to ban their sale for use in capital punishment.

For previous columns regarding lethal injection procedures, see

JANUARY 2014 LETHAL INJECTION WITH MIDAZOLAM AND HYDROMORPHONE . . AN ANESTHESIOLOGIST’S OPINION, and

APRIL 2014 LETHAL INJECTION IN OKLAHOMA . . . AN ANESTHESIOLOGIST’S VIEW.

Note: As a physician who took the Hippocratic Oath to never harm patients, I neither approve of nor would assist in any way in the lethal injection of a prisoner.

 

References:

  1. Eckholm, Erik “Pfizer Blocks the Use of Its Drugs in Executions”The New York Times. May 16, 2016.

 

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

 

 

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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The anesthesiaconsultant.com, copyright 2010, Palo Alto, California

For questions, contact:  rjnov@yahoo.com

 

 

 

 

 

 

 

 

 

 

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