Editing Lethal injection (section)

===Support===

====Commonality====
The combination of a barbiturate induction agent and a nondepolarizing paralytic agent is used in thousands of anesthetics every day. Supporters of the death penalty argue that unless anesthesiologists have been wrong for the past 40 years, the use of pentothal and pancuronium is safe and effective. In fact, potassium is given in heart bypass surgery to induce [[cardioplegia]]. Therefore, the combination of these three drugs remains in use. Supporters of the death penalty speculate that the designers of the lethal-injection protocols intentionally used the same drugs as are used in everyday surgery to avoid controversy. The only modification is that a massive coma-inducing dose of barbiturates is given. In addition, similar protocols have been used in countries that support euthanasia or physician-assisted suicide.<ref name=euthanasics/>

====Anesthesia awareness====
Thiopental is a rapid and effective drug for inducing unconsciousness, since it causes loss of consciousness upon a single circulation through the brain due to its high [[lipophilic]]ity. Only a few other drugs, such as [[methohexital]], [[etomidate]], or [[propofol]], have the capability to induce anesthesia so rapidly. (Narcotics such as fentanyl are inadequate as induction agents for anesthesia.) Supporters argue that since the thiopental is given at a much higher dose than for medically induced coma protocols, it is effectively impossible for the condemned to wake up.

Anesthesia awareness occurs when [[general anesthesia]] is inadequately maintained, for a number of reasons. Typically, anesthesia is 'induced' with an intravenous drug, but 'maintained' with an [[Inhalational anesthetic|inhaled anesthetic]] given by the anesthesiologist or nurse-anesthetist (note that there are several other methods for safely and effectively maintaining anesthesia). Barbiturates are used only for induction of anesthesia and although these drugs rapidly and reliably induce anesthesia,  wear off quickly. A [[Neuromuscular-blocking drugs|neuromuscular-blocking drug]] may then be given to cause paralysis which facilitates [[intubation]], although this is not always required. The anesthesiologist or nurse-anesthetist is responsible for ensuring that the maintenance technique (typically inhalational) is started soon after induction to prevent the patient from waking up.

General anesthesia is not maintained with barbiturate drugs because they are so short-acting. An induction dose of thiopental wears off after a few minutes because the thiopental redistributes from the brain to the rest of the body very quickly. Also thiopental has a long half-life and needs time for the drug to be eliminated from the body. If a very large initial dose is given, little or no redistribution takes place because the body is saturated with the drug; thus recovery of consciousness requires the drug to be eliminated from the body. Because this process is not only slow (taking many hours or days), but also unpredictable in duration, barbiturates are unsatisfactory for the maintenance of anesthesia.

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://www.latimes.com/archives/la-xpm-2006-feb-15-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====
Death-penalty supporters state that the claim that pancuronium dilutes the sodium thiopental dose is erroneous. Supporters argue that pancuronium and thiopental are commonly used together in everyday surgery and that if there were a dilution effect, it would be a known drug interaction.

[[Drug interaction]]s are a complex topic. Simplistically, drug interactions can be classified as either synergistic or inhibitory interactions. In addition, drug interactions can occur directly at the site of action through common pathways, or indirectly through metabolism of the drug in the [[liver]] or through elimination in the [[kidney]]. Pancuronium and thiopental have different sites of action, one in the brain and one at the neuromuscular junction. Since the half-life of thiopental is 11.5 hours, the metabolism of the drugs is not an issue when dealing with the short time frame in lethal injections. The only other plausible interpretation would be a direct one, or one in which the two compounds interact with each other. Supporters of the death penalty argue that this theory does not hold true. They state that even if the 100&nbsp;mg of pancuronium directly prevented 500&nbsp;mg of thiopental from working, sufficient thiopental to induce coma would be present for 50 hours. In addition, if this interaction did occur, then the pancuronium would be incapable of causing paralysis.{{Citation needed|date=June 2009}}

Supporters of the death penalty state that the claim that the pancuronium prevents the thiopental from working, yet is still capable of causing paralysis, is not based on any scientific evidence and is a drug interaction that has never before been documented for any other drugs.{{Citation needed|date=May 2011}}