Presse Med
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Stroke is presently the first cause of brain death in France. In this context, the question of elective non-therapeutic ventilation and resuscitation arises, aiming at enabling the patients for whom a decision to stop all the therapeutics has been made to evolve towards brain death and organ donation. In 2010, the French society of intensive care has released guidelines regarding stroke management including strategy on this topic. The question has also been referred to the Ethics Committee of Nancy university hospital by a chief-nurse of our hospital and we report here its conclusions and propositions. ⋯ Elective intensive care following decision to stop any treatment after severe stroke seems to be justified with regard to public health as well as individual or collective ethics, providing the patient has expressed his/her consent or his/her non-opposition before stroke occurrence. In France there is no legal frame regulating this practice, no information of the general public, and a public debate has yet to be initiated. Regarding the practical details, a priori agreement of the organ procurement organisation, patient's consent, and approval of the consultant required by the law of April 22, 2005 relating to Patients' rights and to the end of life to rule out any conflict of interest, have to be checked before referring the patient to ICU. Advance directives drafting must be developed and their scope extended to organ donation and elective resuscitation. Therefore, fair information of the general public and clarity and transparency of the procedures are needed. The prolongation of the French moratorium on Maastricht III type non-heart beating organ donation - grounded on fears of possible conflicts on interest - seems obsolete with regard to the increasing respect of the patient's autonomy and to the risk of harmfulness entailed by elective resuscitation before death.
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Metformin Associates lactic acidosis (MALA) is a metabolic acidosis with higher anion gap, high levels of blood lactates and treatment by metformin. MALA is a very rare entity but is associated with high mortality (30 to 50%). The extrarenal blood purification may be necessary in emergency. ⋯ There is always a trigger and hypovolemia is prevalent. MALA often occurs when its prescription is not indicated (renal failure, cardiac failure, hypovolemia, or patient aged over 80 years). Metformin must be stopped in situations of acute hypovolemia or frail patients as diuretics or blockers of the rennin-angiotensin-aldosterone system.
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The effect of sedation for intractable distress on survival in terminally ill patients is a debated question. For certain people, this would limit the physician's intervention to the detriment of symptom alleviation for patients. The principle of double effect is traditionally used to overcome this ethical conflict. ⋯ Caution, we think, is necessary, especially as sedation is sometimes used with explicit intention of hastening the end of life. Physician's intention, key point of the principle of double effect, comes back into the foreground of ethical debate on sedation for intractable distress. Far from limiting the physician's action, the principle of double effect, which requires us to clarify our intentions, should allow us to make the distinction between sedation for intractable distress and euthanasia.
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An epidemic of type 4 dengue was raging in the Pacific from 2008 to 2010. During this period, several patients were hospitalized at the Hospital Centre of Tahiti for neurological disorders occurring during a dengue fever. These events are not the typical picture, which is represented by a flu-like syndrome and sometimes, in severe cases, a haemorrhagic syndrome or shock. ⋯ None of observed neurologic disorders presenting with specific manifestation, discussion of dengue as etiology in endemic areas or in return from endemic area is well-founded.