G. Janvier

La dimension médicolégale du consentement éclairé en médecine

The practice of the medical arts is more and more becoming framed by laws and regulations. Concurrently, the civil liability in the medical field has also been deeply changed, in particular by reversing the charge of proof of the information given to the patient. After having been reminded of the place in the juridical arsenal of informed consent to a medical procedure, its value is discussed regarding the explanations given by the physicians. Guidelines for a forensic appraisal, with the aim of evaluating and appreciating the information received by the patient, are proposed. Recent judiciary decisions about refusal of care, especially blood transfusions, are discussed.

Variations hémodynamiques induites par la laparotomie en chirurgie aorto-iliaque

A haemodynamic study was carried out on 53 patients undergoing elective surgery of the abdominal aorta in order to assess the haemodynamic changes consequent to abdominal manipulations prior to aortic clamping. Surgery was carried out under general anaesthesia and ventilation was controlled. The following parameters were monitored : mean arterial pressure (Pa), cardiac index (CI), systolic index (SI), systemic vascular resistances (Rsa), pulmonary vascular resistances (Rpa), heart rate (fC). Cutaneous circulation was monitored using a photoplethysmographic transducer. The following haemodynamic pattern was seen as the peritoneal cavity was opened and traction on the mesenter was applied : CI +40.7 %; fC +28.61 %; SI +9.85 %; Rsa −39.16 %; Rpa −28.43 %; Pa −15.7 %. The recording of the facial cutaneous photoplethysmographic wave showed an increase of 50 %. In some extreme cases, a state of cardiovascular collapse with marked cutaneous erythema strongly resembling anaphylactic shock ensued. The physiopathology of these cardiovascular reactions is unclear, but the haemodynamic pattern as well as the cutaneous vasodilation suggest a stimulation of both vagal and sympathetic nervous systems and the release of vasoactive substances into the general circulation.