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The most popular posts for anesthesia professionals on The Anesthesia Consultant include:

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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

2 May 201431 Oct 2018THE ANESTHESIA CONSULTANT 5 Comments

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THE ANESTHESIA CONSULTANT

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Latest posts by THE ANESTHESIA CONSULTANT (see all)

HIGH FLOW NASAL OXYGEN:AN ANESTHESIA GAME-CHANGER - 15 Nov 2023
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CALL FROM THE JAILHOUSE REVIEW: “I LOVED HOW THE BOOK WAS CRAFTED.” - 15 Sep 2023

On April 29, 2014 CNN reported the story of the botched intravenous lethal injection execution of convicted murderer Clayton Lockett in Oklahoma. The recipe included execution by three anesthetic drugs: midazolam, vecuronium, and potassium chloride.

Prior to the execution, medical officials tried for nearly an hour to find a vein in Clayton Lockett’s arms, legs and neck before finally inserting an IV into his groin, prisons director Robert Patton wrote in a letter to the governor May 1st detailing Lockett’s last day.

In the middle of the injection process, the convict was observed to cry out, “Man,” “I’m not,” and “something’s wrong,” before the blinds were closed to witnesses. Lockett died of a heart attack 43 minutes after the first drug was injected.

Dean Sanderford, Lockett’s attorney, stated his client’s body “started to twitch,” and then “the convulsing got worse. It looked like his whole upper body was trying to lift off the gurney. For a minute, there was chaos.”

After administering the first drug, “We began pushing the second and third drugs in the protocol,” said Oklahoma Department of Corrections Director Robert Patton. “There was some concern at that time that the drugs were not having the effect. So the doctor observed the line and determined that the line had blown.” He said that Lockett’s vein had “exploded.”

CNN further states that, “Oklahoma had announced the drugs it planned to use: midazolam; vecuronium bromide to stop respiration; and potassium chloride to stop the heart. Two intravenous lines are inserted, one in each arm. The drugs are injected by hand-held syringes simultaneously into the two intravenous lines. The sequence is in the order that the drugs are listed above. Three executioners are utilized, with each one injecting one of the drugs.”

The article further states that, “The doctor checked the IV and reported the blood vein had collapsed,and the drugs had either absorbed into tissue, leaked out or both,” according to the timeline. The director of the corrections department then asked whether Lockett had been given enough of the drug combination to kill him, and the doctor said “no.” “Is another vein available? And if so, are there enough drugs remaining?” the doctor was asked, according to the timeline.

The doctor’s answer to both questions: “No.”

Lockett’s attempted execution was carried out at the Oklahoma State Penitentiary in McAlester, where he had been housed following his conviction and death sentence for shooting Stephanie Nieman and then watching as two others buried her alive in 1999.

What happened in this apparent “botched” execution? I have no additional information other than what has been published in the lay press, but as an anesthesiologist I can make some inferences:

In the three drug combination of midazolam, vecuronium, and potassium chloride, each drug has a specific purpose. The sedative midazolam is intended to make the convicted murderer fall asleep. Midazolam (Versed) is a benzodiazepine, a drug commonly given immediately prior to surgery to relieve a patient’s anxiety. A typical adult dose is 2 mg. Midazolam is also commonly used for conscious sedation for colonoscopy procedures, when repeated 1 – 2 mg doses are titrated for relaxation. Let’s assume an executioner administered massive overdoses in the range of 50 mg of midazolam. This dose should reliably guarantee unconsciousness, unless the intravenous catheter is not properly placed inside the vein. If the IV infiltrates, only a portion of the midazolam circulates in the bloodstream, and the expected unconsciousness may not be obtained.

The second drug, vecuronium, is a paralyzing drug. Anesthesiologists commonly inject vecuronium prior to or during surgical anesthetics. Anesthesiologists first administer a hypnotic drug such as propofol to insure unconsciousness, and then administer a muscle relaxant drug such as vecuronium to paralyze the patient so a metal laryngoscope can be inserted into the patient’s mouth to facilitate the placement of a breathing tube into the trachea. The anesthesiologist will then support ventilation of the patient’s lungs by connecting the breathing tube to a ventilator. The paralyzed patient is unable to breathe on their own, and without the controlled ventilation the patient would die within minutes. This is the rationale of using vecuronium in a lethal injection cocktail. The other rationale in using a paralyzing drug such as vecuronium is that a paralyzed individual will not writhe or seize during the death process.

A concentrated dose of potassium chloride causes sudden cardiac arrest by ventricular fibrillation of the heart.

Why did the Oklahoma execution not go smoothly? As reported in the press, the intravenous line infiltrated. Why does this happen? The intravenous line was either improperly inserted, improperly secured, or it dislodged. The success of a lethal injection depends specifically on the lethal drugs being reliably delivered into the convict’s vein via a properly running IV line.

Some individuals have difficult IV access, which apparently was the case in the convict Lockett. Medical personnel typically place IV’s in arm veins, followed by legs, neck or groin as alternate locations. The placement of an IV in the groin, as was reported in Lockett’s case, is typically done by a physician, utilizing a longer IV catheter called a central venous catheter or CVP catheter. In modern hospitals, this CVP placement is often done using ultrasound imaging for increased accuracy and success. In a hospital setting, CVP placement would be done by an M.D., not by a nurse or a technician.

What was the mechanism of Lockett’s heart attack and death? I don’t know for sure, but possibilities are: 1) enough potassium chloride accumulated in his blood stream to cause his heart to arrest; 2) enough vecuronium accumulated in his blood stream to weaken his breathing so that he could not ventilate his own lungs with oxygen; or 3) a combination of 1) and 2).

Dr. Jack Kevorkian invented a euthanasia machine for assisted suicide. His machine injected three drugs that parallel the drugs used in Oklahoma: the sleep drug sodium thiopental, the paralyzing drug pancuronium, and potassium chloride. In 1999 Kevorkian was arrested for his role in executing patients in the fashion. Kevorkian was convicted of second-degree murder.

The manufacturer of the sleep drug sodium thiopental has banned the use of the product for lethal injection of prisoners. Because of this ban, there have been recent occurrences of midazolam replacing thiopental in the lethal injection recipe in the United States in 2014.

A second midazolam execution occurred in January 2014, during the lethal injection of convicted murderer Dennis McGuire at the Southern Ohio Correctional Facility in Lucasville, Ohio. This was the first time any state used the combination of midazolam and hydromorphone for an execution. It was reported that McGuire took 15 minutes to die. A reporter who witnessed the execution described McGuire as struggling, gasping loudly, snorting and making choking noises for nearly 10 minutes before falling silent and being declared dead a few minutes later. Dennis McGuire’s execution was discussed in an earlier blog entry (http://theanesthesiaconsultant.com/2014/01/16/january-2014-lethal-injection-with-midazolam-and-hydromorphone/).

Is midazolam an inferior drug to sodium thiopental for lethal injection? Probably not. In sufficiently high doses, midazolam will make any individual unconscious. An apparent flaw in McGuire’s case was the absence of a paralyzing drug and potassium chloride in the recipe. The apparent flaw in Lockett’s case was the absence of a reliable functioning IV.

Will an anesthesiologist ever insert the IV and supervise a lethal injection on death row? No. No anesthesiologist will ever use his or her skills to end a human’s life. State governments will have to find someone else to supervise lethal injections. An anesthesia doctor’s job is to keep patients alive.

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

The most popular posts for anesthesia professionals on The Anesthesia Consultant include:

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:

JANUARY 2014 LETHAL INJECTION WITH MIDAZOLAM AND HYDROMORPHONE … AN ANESTHESIOLOGIST’S OPINION

16 Jan 20141 Nov 2018THE ANESTHESIA CONSULTANT 5 Comments

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THE ANESTHESIA CONSULTANT

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Latest posts by THE ANESTHESIA CONSULTANT (see all)

HIGH FLOW NASAL OXYGEN:AN ANESTHESIA GAME-CHANGER - 15 Nov 2023
STANFORD EMERGENCY MANUAL POCKET VERSION - 28 Sep 2023
CALL FROM THE JAILHOUSE REVIEW: “I LOVED HOW THE BOOK WAS CRAFTED.” - 15 Sep 2023

On January 16, 2014, the New York Times reported that Dennis McGuire was executed by a lethal injection of midazolam and hydromorphone. McGuire was previously convicted of the 1994 rape and murder of a 22-year-old pregnant woman.

The lethal injection occurred at the Southern Ohio Correctional Facility in Lucasville, Ohio. It was the first time any state used the combination of midazolam and hydromorphone for an execution. It was reported that McGuire took 15 minutes to die. A reporter who witnessed the execution described McGuire as struggling, gasping loudly, snorting and making choking noises for nearly 10 minutes before falling silent and being declared dead a few minutes later.

What happens to a human when you inject midazolam and hydromorphone? Anesthesiologists use these drugs every day to provide safe anesthesia care in operating rooms.

Midazolam (Versed) is a benzodiazepine, a drug commonly given immediately prior to surgery to relieve a patient’s anxiety. A typical adult dose is 2 mg. Midazolam is also commonly used for conscious sedation for colonoscopy procedures, when repeated 1 – 2 mg doses are titrated for relaxation.

Hydromorphone (Dilaudid) is a narcotic similar to morphine. Physicians inject Dilaudid to relieve pain. A typical adult intravenous dose is 0.2 mg. Doses may be repeated and titrated to effect if the patient continues to hurt.

Both midazolam and hydromorphone are respiratory depressants. When administered together in high doses, these two drugs will (1) cause unconsciousness, and (2) depress breathing, and perhaps cause breathing to cease if the doses are high enough.

When anesthesiologists inject doses of midazolam and hydromorphone we routinely administer supplemental oxygen, and monitor the patient with a pulse oximeter, an ECG machine, an end-tidal carbon dioxide monitor and a blood pressure cuffs. Anesthesiologists give moderate doses of midazolam and hydromorphone safely every day.

Can you kill someone with mega-doses of these two drugs? Absolutely. I have no idea what doses were used in the Ohio execution, but let’s assume an executioner administered massive overdoses in the range of 50 mg of midazolam and 5 mg of hydromorphone. The mechanism of death would be hypoventilation and hypoxia. In layman’s terms this means the patient’s ventilation will decrease markedly, and because of this decreased breathing the patient’s oxygen level will decrease. If the oxygen level decreases to a lethal level–a level low enough that the heart and brain will have inadequate oxygen–the patient will have a cardiac arrest. Can 10 -15 minutes pass by before the inadequate oxygen levels cause cardiac arrest? Yes, they could.

Would a patient dying in this fashion suffer? No, it’s unlikely they will suffer. If the doses of midazolam and hydromorphone are large enough, the patient will be unconscious before and during their cardiac death.

Will an anesthesiologist ever supervise such a lethal injection on death row? No. Per my earlier blog entry, ANESTHESIA FACTS FOR NONMEDICAL PEOPLE: LETHAL INJECTION AND THE ANESTHESIOLOGIST, listed in the column at your right, no anesthesiologist will ever use his or her skills to end a human’s life.

State governments will have to find someone else to supervise lethal injections. An anesthesia doctor’s job is to keep patients alive.

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

The most popular posts for anesthesia professionals on The Anesthesia Consultant include:

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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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:

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:

LETHAL INJECTION AND THE ANESTHESIOLOGIST

3 Oct 20131 Nov 2018THE ANESTHESIA CONSULTANT Leave a comment

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THE ANESTHESIA CONSULTANT

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Latest posts by THE ANESTHESIA CONSULTANT (see all)

HIGH FLOW NASAL OXYGEN:AN ANESTHESIA GAME-CHANGER - 15 Nov 2023
STANFORD EMERGENCY MANUAL POCKET VERSION - 28 Sep 2023
CALL FROM THE JAILHOUSE REVIEW: “I LOVED HOW THE BOOK WAS CRAFTED.” - 15 Sep 2023

Lethal injection requires someone to administer anesthetic medications in high concentrations, without supporting breathing or cardiac function. This column discusses lethal injection and the anesthesiologist. In the 2011 movie The Lincoln Lawyer, Matthew McConaughey’s character, a criminal defense lawyer working in Los Angeles, taunts his client who is on trial for murder to tell the truth in order to “avoid the needle.” The needle he is talking about is the specter of execution by lethal injection.

lethal injection and the anesthesiologist

Since 2006, there have been no death penalty executions by lethal injection in the state of California. In February 2006, U.S. District Court Judge Jeremy D. Fogel blocked the execution of convicted murderer Michael Morales because of concerns that if the three-drug lethal injection combination was administered incorrectly, it could lead to suffering for the condemned, and potential cruel and unusual punishment. The ruling arose from an injunction made by the U.S. 9th Circuit Court of Appeals, which stated that an execution could only be carried out by a medical technician legally authorized to administer intravenous medications. This led to a moratorium of capital punishment in California, as the state was unable to obtain the services of a licensed medical professional to carry out an execution.

The three intravenous drugs involved in lethal injection are (1) sodium thiopental, a barbiturate drug that induces sleep, (2) pancuronium, a drug that paralyzes all muscles, making movement and breathing impossible, and (3) potassium chloride, a drug that induces ventricular fibrillation of the heart, causing cardiac arrest. The potential of cruel and unusual punishment can occur if the sodium thiopental does not reliably induce sleep, so that the individual to be executed is awake and aware when the paralyzing drug freezes all muscular activity.

How could sodium thiopental fail to induce sleep? The lethal injection administered dose of sodium thiopental is always a massive dose, up to 3000 mg. To compare, the usual dose of sodium thiopental administered by an anesthesiologist to begin a general anesthetic is 200 mg. The 15-fold increase in the dose should insure lack of awareness, right?

Not necessarily. What if the intravenous catheter or needle is incorrectly positioned, so that the drug does not enter the vein in a reliable fashion? Is this a possibility? It is. If the catheter is not inserted by a trained medical professional, it’s possible that the catheter will be outside of the vein, and the intended medications will spill into the soft tissues of the arm. The intended site of action of sodium thiopental is the brain. To reach the brain, the drug must be correctly delivered into a vein.

Cases in which failure to establish or maintain intravenous access have led to executions lasting up to 90 minutes before the execution was complete.Thus, the role of a medical professional to insert the intravenous catheter and administer the lethal injection is critical. The dilemma is that medical professionals are trained to save lives, not to execute people. The Hippocratic Oath clearly states that physicians must “do no harm” to their patients.

The American Society of Anesthesiologists states, “Although lethal injection mimics certain technical aspects of the practice of anesthesia, capital punishment in any form is not the practice of medicine … The American Society of Anesthesiologists continues to agree with the position of the American Medical Association on physician involvement in capital punishment. The American Society of Anesthesiologists strongly discourages participation by anesthesiologists in executions.”

In 2010, a Riverside County judge scheduled the execution of Albert Greenwood Brown, after a California court lifted an injunction against capital punishment with the certification of new procedures. The new procedures included the option of increasing the sodium thiopental dose to 5000 mg, and administering the drug alone without the pancuronium and potassium chloride. (In this scenario, death would occur because the large dose of sodium thiopental would by itself induce both general anesthesia and the cessation of breathing, leading to death by lack of sufficient oxygen levels to the brain and heart.) However, prior to the execution, the same Judge Jeremy D. Fogel halted the execution to permit time to determine whether the new injection procedures addressed defense arguments of cruel and unusual punishment.

An additional barrier to lethal injection arose in January 2011, as Hospira Corporation, the sole manufacturer of sodium thiopental, announced that they would stop making the anesthetic sodium thiopental, the key component in the drug cocktails used by 35 states for chemical executions.

Hospira had planned to shift production of thiopental from the U.S. to Italy, but Italian officials wanted assurances that the drug would not be used for lethal injections. Hospira’s response was that while they “never condoned” the use of thiopental in executions, the company determined that it could not prevent corrections departments in the United States from obtaining the drug. “Based on this understanding, we cannot take the risk that we will be held liable by the Italian authorities if the product is diverted for use in capital punishment,” Hospira said in a statement.

The American Society of Anesthesiologists released a statement on January 21, 2011 condemning Hospira’s decision to cease manufacturing sodium thiopental. The American Society of Anesthesiologists “certainly does not condone the use of sodium thiopental for capital punishment, but we also do not condone using the issue as the basis to place undue burdens on the distribution of this critical drug to the United States. It is an unfortunate irony that many more lives will be lost or put in jeopardy as a result of not having the drug available for its legitimate medical use.” According to the American Society of Anesthesiologists, thiopental is an important alternative for geriatric, neurologic, cardiovascular and obstetric patients “for whom the side effects of other medications could lead to serious complications.”

In current anesthetic practice in the U.S. and around the world, sodium thiopental is occasionally but rarely utilized in anesthetic or intensive care unit practice. Propofol replaced sodium thiopental, as propofol is a shorter-acting drug with fewer side effects of post-operative sleepiness and nausea.

Propofol or other sedative drugs such as midazolam, Valium, etomidate, or methohexital could be used to replace sodium thiopental to carry out lethal injection, but the key issue of obtaining a trained medical professional to administer the drug still looms as a roadblock.

I recommend The Lincoln Lawyer as riveting entertainment, but when Matthew McConaughey urges the defendant to “avoid the needle” of lethal injection, you have to understand … it’s unlikely any anesthesiologist is ever going to assist in that execution.

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

The most popular posts for anesthesia professionals on The Anesthesia Consultant include:

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?