Issues surrounding lethal injection as a means of capital punishment.

Lethal injection as a method of state-sanctioned capital punishment was initially proposed in the United States in 1977 and used for the first time in 1982. Most lethal injection protocols use a sequential drug combination of sodium thiopental, pancuronium bromide, and potassium chloride. Lethal injection was originally introduced as a more humane form of execution compared with existing mechanical methods such as electrocution, toxic gassing, hanging, or firing squad. Lethal injection has not, however, been without controversy. Several states are considering whether lethal injection meets constitutional scrutiny forbidding cruel and unusual punishment. Recently in the case of Ralph Baze and Thomas C. Bowling, Petitioners, v John D. Rees, Commissioner, Kentucky Department of Corrections et al, the United States Supreme Court upheld the constitutionality of the lethal injection protocol as carried out in the Commonwealth of Kentucky. Most of the debate has surrounded the dosing and procedures used in lethal injection and whether the drug combinations and measures for administering the drugs truly produce a timely, pain-free, and fail-safe death. Many have also raised issues regarding the "medicalization" of execution and the ethics of health care professionals' participation in any part of the lethal injection process. As a result of all these issues, the future of lethal injection as a means of execution in the United States is under significant scrutiny. Outcomes of ongoing legislative and judicial reviews might result in cessation of lethal injection in totality or in alterations involving specific drug combinations or administration procedures.

The medical-legal quandary of healthcare in capital punishment: an ethical dilemma for the anesthesia provider.

The case of Brase v Rees was presented before the US Supreme Court to consider the constitutionality of death by lethal injection as practiced in the state of Kentucky. The 3-drug combination of sodium thiopental, pancuronium bromide, and potassium chloride is a key aspect in question. Capital punishment conflicts with medical and nursing code of ethics preventing providers who are skilled at difficult intravenous (IV) access, assessment of appropriate sedation, and involvement without fear of disciplinary action. Therefore, untrained or undertrained personnel from the prison have been delegated these duties. Cases in which failure to establish or maintain IV access has led to executions lasting up to 90 minutes before the execution was complete. Participation by skilled medical personnel has been a debate between the medical and legal communities since the inception of lethal injection. Healthcare should reevaluate the ethical and moral principle of beneficence as the legal system attempts to evaluate the constitutionality of lethal injection. Can a nurse or doctor step out of the role of medical professional, use knowledge and skill to make death by lethal injection more humane, and not violate the ethical principle of "do no harm"?

Lethal injection for execution: chemical asphyxiation?

BACKGROUND: Lethal injection for execution was conceived as a comparatively humane alternative to electrocution or cyanide gas. The current protocols are based on one improvised by a medical examiner and an anesthesiologist in Oklahoma and are practiced on an ad hoc basis at the discretion of prison personnel. Each drug used, the ultrashort-acting barbiturate thiopental, the neuromuscular blocker pancuronium bromide, and the electrolyte potassium chloride, was expected to be lethal alone, while the combination was intended to produce anesthesia then death due to respiratory and cardiac arrest. We sought to determine whether the current drug regimen results in death in the manner intended. METHODS AND FINDINGS: We analyzed data from two US states that release information on executions, North Carolina and California, as well as the published clinical, laboratory, and veterinary animal experience. Execution outcomes from North Carolina and California together with interspecies dosage scaling of thiopental effects suggest that in the current practice of lethal injection, thiopental might not be fatal and might be insufficient to induce surgical anesthesia for the duration of the execution. Furthermore, evidence from North Carolina, California, and Virginia indicates that potassium chloride in lethal injection does not reliably induce cardiac arrest. CONCLUSIONS: We were able to analyze only a limited number of executions. However, our findings suggest that current lethal injection protocols may not reliably effect death through the mechanisms intended, indicating a failure of design and implementation. If thiopental and potassium chloride fail to cause anesthesia and cardiac arrest, potentially aware inmates could die through pancuronium-induced asphyxiation. Thus the conventional view of lethal injection leading to an invariably peaceful and painless death is questionable.

Inadequate anaesthesia in lethal injection for execution.

Anaesthesia during lethal injection is essential to minimise suffering and to maintain public acceptance of the practice. Lethal injection is usually done by sequential administration of thiopental, pancuronium, and potassium chloride. Protocol information from Texas and Virginia showed that executioners had no anaesthesia training, drugs were administered remotely with no monitoring for anaesthesia, data were not recorded and no peer-review was done. Toxicology reports from Arizona, Georgia, North Carolina, and South Carolina showed that post-mortem concentrations of thiopental in the blood were lower than that required for surgery in 43 of 49 executed inmates (88%); 21 (43%) inmates had concentrations consistent with awareness. Methods of lethal injection anaesthesia are flawed and some inmates might experience awareness and suffering during execution.

Paralysis has no effect on chest wall and respiratory system mechanics of mechanically ventilated, sedated patients.

OBJECTIVE: To evaluate the separate effects of sedation and paralysis on chest wall and respiratory system mechanics of mechanically ventilated, critically ill patients. SETTING: ICU of the University "La Sapienza" Hospital, Rome. PATIENTS AND PARTICIPANTS: 13 critically ill patients were enrolled in this study. All were affected by disease involving both lungs and chest wall mechanics (ARDS in 4 patients, closed chest trauma without flail chest in 4 patients, cardiogenic pulmonary oedema with fluidic overload in 5 patients). MEASUREMENTS AND RESULTS: Respiratory system and chest wall mechanics were evaluated during constant flow controlled mechanical ventilation in basal conditions (i.e. with the patients under apnoic sedation) and after paralysis with pancuronium bromide. In details, we simultaneously recorded airflow, tracheal pressure, esophageal pressure and tidal volume; with the end-inspiratory and end-expiratory airway occlusion technique we could evaluate respiratory system and chest wall elastance and resistances. Lung mechanics was evaluated by subtracting chest wall from respiratory system data. All data obtained in basal conditions (with the patients sedated with thiopental or propofol) and after muscle paralysis were compared using the Student's t test for paired data. The administration of pancuronium bromide to sedated patients induced a complete muscle paralysis without producing significant modification both to the viscoelastic and to the resistive parameters of chest wall and respiratory system. CONCLUSIONS: This study demonstrates the lack of additive effects of muscle paralysis in mechanically ventilated, sedated patients. Also in view of the possible side effects of muscle paralysis, our results question the usefulness of generalized administration of neuromuscular blocking drugs in mechanically ventilated patients.

Effects of general anaesthesia on the intraocular pressure in man. Trichloroethylene in nitrous oxide and oxygen.

The effect of TCE on the intraocular pressure was investigated in eight patients under thiopentone nitrous oxide/oxygen anaesthesia, using a muscle relaxant (pancuronium bromide). Pulmonary ventilation was controlled and the end-tidal carbon dioxide was maintained at 5 per cent. In every patient the intraocular pressure was observed to rise as TCE was administered and then to return to the initial level when the administration of TCE ceased.

A suicide by pancuronium bromide injection: evaluation of the fluorometric determination of pancuronium in postmortem blood, serum and urine.

A fatal case of suicidal injection of pancuronium bromide is presented. Pancuronium was detected in blood and urine by ion-pair extraction and fluorometry. An evaluation of the fluorometric procedure for the determination of pancuronium in postmortem blood, serum and urine is presented. Stability of the extracted ion-pair, possible interferences from other drugs, and the effects of specimen storage were studied.

Effect of prior administration of a non-depolarising muscle relaxant on the action of suxamethonium in the dog.

The non-depolarising muscle relaxants alcuronium (0.1 mg kg-1), gallamine (1 mg kg-1) and pancuronium (0.06 mg kg-1) were administered to six dogs. At 50 per cent return of neuromuscular activity, as measured by the train-of-four technique, the depolarising muscle relaxant suxamethonium (0.3 mg kg-1) was injected intravenously. At 50 per cent return of neuromuscular activity, atropine and neostigmine were administered to reverse the neuromuscular block. The duration of action of suxamethonium was reduced by each of the non-depolarising muscle relaxants.

Anaesthesia with continuous thiopentone infusion, epidural morphine and relaxant.

Twenty-three patients undergoing surgery below T.6 dermatome were anaesthetized with epidural morphine 20 mg in 15 ml of saline, thiopentone drip 0.04-0.1 mg/kg/min. and pancuronium 0.1 mg/kg. The patients had satisfactory analgesia intra-operatively. Post-operative analgesia lasted for varying periods ranging from 13 hours to 24 hours and above. The cardiovascular system was stable. Post-epidural morphine complications of respiratory depression (three patients), urinary retention (one patient) and pruritus (one patient) were seen and they were managed successfully.

Infusion of large particles of thiopental sodium during anesthesia induction.

STUDY OBJECTIVE: To determine the potential clinical significance of admixtures of thiopental sodium and acidic drugs, which are used during induction of general anesthesia and can cause the formation of particles of thiopental. DESIGN: Using an infusion setup similar to that used for a rapid-sequence induction of general anesthesia, injection of either pancuronium bromide or vecuronium bromide caused formation of particles of thiopental that were measured using a particle analyzer. The effects of delaying the injection of the muscle relaxant on particle formation and the effects of plasma on particle dissolution were studied. MEASUREMENTS AND MAIN RESULTS: The thiopental particles had a diameter of 17 to 39 microns, with a concentration of 15,000 to 20,000 particles/ml. Particle formation was prevented when a 30-second delay preceded administration of pancuronium or vecuronium following injection of thiopental. No particle formation was detected when succinylcholine was injected. Human plasma was far more effective than a crystalloid solution in dissolving thiopental particles. CONCLUSIONS: It is unlikely that clinically significant particles of thiopental will remain intact upon entering the bloodstream. However, mixing thiopental with pancuronium or vecuronium has the potential of disrupting intravenous access due to occlusion with particles.

Effect of halothane on bronchial calibre of anaesthetised cattle.

A computer-aided forced oscillation technique was used to examine the effects of halothane on bronchial calibre in three adult cows after anaesthesia had been induced with xylazine and thiopentone. The administration of halothane failed to produce bronchodilatation, possibly owing to low resting bronchomotor tone in the animals. However, an increase in expiratory reserve volume, associated with a small fall in airway resistance, was observed, suggesting that changes in elastic recoil may make a significant contribution to changes in airway resistance during anaesthesia. The results also emphasise the importance of relating airway resistance to lung volume.

Pseudocholinesterase changes in anesthesia using pancuronium.

Pseudocholinesterase activity was investigated in three groups of unselected patients. A slight rise of the enzyme was found during surgery under local anesthesia with lidocaine. In general anesthesia with thiopentone and halothane, the pseudocholinesterase activity diminished. The inhibition was more pronounced when pancuronium had been injected. From these data one may conclude that pancuronium must be carefully given in patients with low level of pseudocholinesterase when other drugs inhibiting the enzyme activity, like succinylcholine, procaine and propanidid, are used.

Metabolic response to anaesthesia and lower abdominal surgery in Nigerians. Changes in plasma cortisol and blood sugar.

In ten Nigerian patients undergoing prostatectomy, plasma cortisol was slightly decreased by pre-medication with atropine and pethidine and during general anaesthesia without surgery. This decrease was not statistically significant. There was, however, a statistically significant increase in plasma cortisol after 1 h of surgery and also in the post-operative period. The blood sugar was elevated by pre-medication and surgery though the rise was not significant. There was a significant rise of blood sugar after 30 min of surgery and in the post-operative period. These findings in general are similar to those observed in ten Nigerian patients undergoing upper abdominal surgery, although the rise in plasma cortisol was higher following upper abdominal surgery, and the rise in blood sugar higher following lower abdominal surgery.

Anesthetic management of conray toxicity.

Conray (meglumine iothalamate), the contrast media frequently used in shuntograms for diagnosing malfunctioning ventriculo-peritoneal shunts, will occasionally cause severe muscular spasms and seizures. In this article, the authors describe anesthetic and critical care management of a case with this complication.

[Interaction between vecuronium and pancuronium].

Interaction between vecuronium bromide (VB) and pancuronium bromide (PB) with regard to a change in duration of action was investigated in 32 elective surgical patients divided into four groups. Initial and supplemental drugs were as follow; group I: VB-->VB, group II: PB-->VB, group III: VB-->PB, group IV: PB-->PB. The muscle response was quantified electromyographically. Anesthesia was induced with thiopental. VB or PB 0.08 mg.kg-1 (initial dose) was given to facilitate endotracheal intubation. Anesthesia was maintained with 66% nitrous oxide and 2% sevoflurane in oxygen. Supplemental dose (0.015 mg.kg-1) of the muscle relaxants was administered at 10% recovery of twitch height. Duration of action was defined as the interval between administration and 10% recovery. Duration of action of supplemental doses of VB was significantly longer in group II than in group I. That of PB was significantly shorter in group III than in group IV. Therefore, it should be noticed that duration of action of supplemental relaxant is largely modified by the initial one.

[Comparison of the effects of midazolam and thiopental on the neuromuscular response of vecuronium, atracurium, and pancuronium]. / Comparación de los efectos del midazolam y del tiopental en la respuesta neuromuscular del vecuronio, atracurio y pancuronio.

To assess the possible interactions of midazolam and thiopental with the muscular relaxants vecuronium (0.08 mg/kg), atracurium (0.5 mg/kg), and pancuronium (0.1 mg/kg), a comparative analysis was undertaken in two groups of 18 and 32 patients treated respectively with midazolam (0.3 mg/kg) and thiopental (5 mg/kg). The beginning of the effect, maximal blockade, duration of the clinical response, and the spontaneous recovery index were measured on electromyographic recordings of action potentials evoked by train of four supramaximal stimuli delivered every 20 sec on the ulnar nerve. Conditions for intubation were assessed 2 minutes after administration of muscular relaxant. There were no significant differences in neuromuscular parameters in either of the two groups of patients treated with midazolam or with thiopental independently of the relaxant drug administered.

Medication errors in anaesthetic practice: a report of two cases and review of the literature.

BACKGROUND: Mistakes in the identification and administration of drugs may be fatal. This is especially so in the practice of anaesthesia. This is a report of 2 cases of near fatality due to mistakes in drug administration from look-alike medications. OBJECTIVE: To highlight the significance of medication errors in our practice and to discuss the best methods of prevention. METHOD: A report of two cases of errors in the administration of drugs during the conduct of anaesthesia. The subsequent management of the cases is presented, and the findings from the literature are discussed. RESULT: In case 1, an adult male presented for herniorrhaphy and after induction with propofol 1mg/kg intravenously, Pancuronium bromide injection 4 mg was administered intravenously, in the place of suxamethonium chloride injection. In case 2, For induction of anaesthesia, 100mg of thiopentone sodium was administered in place of 25mg of the same drug because Thiopentone 1 gm vial was mistaken for Thiopentone 500 mg vial in a 2 year old girl. In both cases, the errors were detected early and there were no adverse sequelae. CONCLUSION: Medication errors are a potential source of iatrogenic harm to patients undergoing anaesthesia. Strict adherence to principles as well as constant vigilance would minimize this problem.