Presse Med
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The incidence of allergic reactions to local anesthetics is low. Most cases involve a psychogenic reaction rather than an allergic reaction. ⋯ Vascular resorption of epinephrine-containing local anesthetics may produce cardiovascular signs similar to an allergic reaction. Diagnosis of allergy to local anesthetics must be established by skin testing and provocative challenge.
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Allergy to neuromuscular blocking agents (NMBAs) has been the first cause of perioperative anaphylaxis for decades, in most countries. The most frequently involved agents are suxamethonium and rocuronium. ⋯ In cases of true allergy, assessing cross-reactivity to other NMBAs is mandatory. The cross-sensitization hypothesis is presently being investigated and if confirmed, it could allow primary prevention measures to be implemented.
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The diagnosis of a perioperative allergic reaction is based on clinical features associated with a suggestive timeline, the exclusion of other diagnoses, elevated concentrations of degranulation markers (histamine, tryptase), and positive allergy assessments (skin tests, specific IgE). After initiating appropriate treatment, the anesthesiologist should take blood samples to measure histamine and tryptase concentrations just after the reaction and repeat them 1-2hours later to validate the diagnosis of immediate hypersensitivity. A delayed measurement of basal tryptase is useful to rule out mastocytosis and to interpret moderate tryptase levels. ⋯ Provocation tests are sometimes required. After allergy assessment, the safest protocol for subsequent anesthesia is determined in collaboration with the anesthesiologist. The patient must be informed and carry an allergy alert card.
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Continuous sedation until death (CSUD) is a practice which has developed recently in several countries, appearing more acceptable than euthanasia and medically assisted suicide, since more close to a "natural death". The French parliament has just adopted a law which stipulates CSUD on request of the patient in a definite number of circumstances, especially in incurable diseases near to the terminal stage with suffering refractory to treatments. Thus France has adopted a unique international position for the end-of-life care. ⋯ The primacy allocated to autonomy is questionable for the more vulnerable patients, who deserve mainly a social solidarity. The double-effect principle is replaced actually in CSUD by a co-intention both to relieve suffering and meanwhile eventually to hasten death, especially when stopping nutrition and hydration. CSUD is thus located in a grey zone between palliative care and euthanasia.
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Preeclampsia is a hypertensive disease of pregnancy due to abnormal utero-placental circulation. Hypoperfusion of the placenta and hypoxia/reoxygenation of the intervillous space are responsible of placental dysfunction. Trophoblastic factors are released in the maternal circulation and are responsible of the maternal endothelial dysfunction that characterize preeclampsia. Among those factors, the PlGF/sFlt-1 couple plays a major pathophysiologic role.