La Biochimica Forense: Stato dell'Arte, Prospettive Future e Presentazione di un Caso di Responsabilità Professionale Medica.

Post-mortem biochemistry: state of the art, possible applications and illustration of a case of medical liability. The aim of this work is to share with the scientific community the usefulness of post7mortem biochemistry as a complementary tool in forensic practice. The authors illustrate a practical application of this discipline presenting a case in which biochemical analysis of blood and vitreous obtained from the body resulted as fundamental in order to reach the more complete understanding of the pathophysiological mechanisms that may be involved in the death process and, consequently, properly answer about Public Prosecutor's questions concerning medical liability profiles. Particularly, an autopsy case involving a 70 year7old7woman suffering from diabetes mellitus and impaired renal function who received metformin treatment is described. Metformin is an oral anti7hyperglycemic agent used in the management of type 2 diabetes mellitus, and it is eliminated by the kidneys. Lactic acidosis from metformin overdose is a rare complication of metformin therapy and occurs infrequently with therapeutic use. Fatal cases, both accidental and intentional, are extremely rare in clinical practice. In the presented case metformin concentrations in peripheral blood collected during hospitalization and femoral blood collected during autopsy were 42 µg/ml and 47.3 µg/ml respectively. Lactic acidosis (29.10 mmol/l) was objectified during hospitalization. Furthermore, post7mortem biochemistry allowed ketoacidosis to be diagnosed (blood β7hydroxybutyrate 10500 µmol/l). Death was attributed to lactic acidosis due to metformin intoxication. Increased plasma concentrations of the drug were attributed to severely impaired renal function. Accordingly, the forensic investigations led to the accused clinicians being considered guilty of manslaughter by the Public Prosecutor.