In this series, the 95% CI for the frequency of epidural hematoma requiring laminectomy after epidural catheter placement for perioperative anesthesia/analgesia was 1 event per 22,189 placements to 1 event per 4330 placements. Risk was significantly lower in obstetric epidurals.

BackgroundMany patients have serious depression that is nonresponsive to medications, but refuse electroconvulsive therapy (ECT). Early research suggested that isoflurane anesthesia may be an effective alternative to ECT. Subsequent studies altered drug, dose or number of treatments, and failed to replicate this success, halting research on isoflurane's antidepressant effects for a decade. Our aim was to re-examine whether isoflurane has antidepressant effects comparable to ECT, with less adverse effects on cognition.MethodPatients with medication-refractory depression received an average of 10 treatments of bifrontal ECT (n = 20) or isoflurane (n = 8) over 3 weeks. Depression severity (Hamilton Rating Scale for Depression-24) and neurocognitive responses (anterograde and retrograde memory, processing speed and verbal fluency) were assessed at Pretreatment, Post all treatments and 4-week Follow-up.ResultsBoth treatments produced significant reductions in depression scores at Post-treatment and 4-week Follow-up; however, ECT had modestly better antidepressant effect at follow-up in severity-matched patients. Immediately Post-treatment, ECT (but not isoflurane) patients showed declines in memory, fluency, and processing speed. At Follow-up, only autobiographical memory remained below Pretreatment level for ECT patients, but isoflurane patients had greater test-retest neurocognitive score improvement.ConclusionsOur data reconfirm that isoflurane has an antidepressant effect approaching ECT with less adverse neurocognitive effects, and reinforce the need for a larger clinical trial.

The cuff of the ETT is a reliable site for measuring body-core temperature in intubated patients.

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Objective. To evaluate leukocyte gene expression for 9 selected genes (mRNAs) as biological markers in patients with medication refractory depression before and after treatment with ECT or isoflurane anesthesia (ISO). Methods. In a substudy of a nonrandomized open-label trial comparing effects of ECT to ISO therapy, blood samples were obtained before and after treatment from 22 patients with refractory depression, and leukocyte mRNA was assessed by quantitative PCR. Patients' mRNAs were also compared to 17 healthy controls. Results. Relative to controls, patients before treatment showed significantly higher IL10 and DBI and lower ADRA2A and ASIC3 mRNA (P < 0.025). Both ECT and ISO induced significant decreases after treatment in 4 genes: IL10, NR3C1, DRD4, and Sult1A1. After treatment, patients' DBI, ASIC3, and ADRA2A mRNA remained dysregulated. Conclusion. Significant differences from controls and/or significant changes after ECT or ISO treatment were observed for 7 of the 9 mRNAs studied. Decreased expression of 4 genes after effective treatment with either ECT or ISO suggests possible overlap of underlying mechanisms. Three genes showing dysregulation before and after treatment may be trait-like biomarkers of medication refractory depression. Gene expression for these patients has the potential to facilitate diagnosis, clarify pathophysiology, and identify potential biomarkers for treatment effects.

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synthesis is postulated to have antiandrogenic effects, leading to a slightly increased risk of congenital cryptorchism. Prostaglandins also influence renal blood flow and glomerular filtration rate. The incidence of renal dysfunction in the setting of maternal NSAID use ranges from 1.5% to 20%, with risk increasing as exposure occurs closer to delivery. Fetal effects of in utero NSAID exposure range from transient fetal oligohydramnios to lethal neonatal renal failure. Prostaglandins also play a primary role in maintaining patency of the ductus arteriosus. Nonsteroidal anti-inflammatory drugYinduced constriction of the ductus arteriosus can lead to neonatal pulmonary hypertension. Although constriction of the ductus arteriosus resolves within 24 hours of NSAID cessation, the transient premature closure is thought to cause enduring ischemic injury to the vascular muscle wall. The damaged ductus arteriosus is subsequently less responsive to increases in oxygen tension, leading to detrimental patency of the ductus arteriosus after delivery. Finally, the antiplatelet effects of aspirin have been implicated in the increased incidence of neonatal bleeding after premature delivery in women with recent exposure to high-dose aspirin (325Y600 mg). Although limited use of small doses of NSAIDs and aspirin during the second and third trimester is probably safe, continuous or excessive inhibition of prostaglandin, prostacyclin, and thromboxane synthesis may have enduring urogenital, pulmonary, and/or hematologic fetal effects.After delivery, breast-feeding offers continued infant exposure to both beneficial and, rarely, harmful maternal serum components. The fraction of maternal drug detected in the breast milk depends on the dose as well as the specific drug characteristics. Nonsteroidal anti-inflammatory drugs are acidic medications with low lipid solubility and high protein binding, features that mitigate against substantial transfer into breast milk. In addition, because NSAIDs are extensively protein-bound, gastrointestinal absorption is limited, and the infant is generally exposed to less than 1% of the initial maternal dose. As a result, nonselective NSAIDs are listed as compatible with breast-feeding by the American Academy of Pediatrics. Aspirin, on the other hand, should be used with caution or avoided, during breast-feeding. Infants have immature enzymes and metabolic pathways. Reduced clearance of aspirin by neonates could potentially lead to accumulation and toxic effects even when repeated exposures are small. Although the adverse effects of aspirin on platelet function are a theoretical risk, the World Health Organization Working Group on Human Lactation has classified aspirin as unsafe for use by nursing women. Neither NSAIDs nor aspirin is completely devoid of neonatal risk. Even if neonatal exposure is low, there is the possibility the infant may be allergic to the drug or especially sensitive to the adverse effect profile. For that reason, when a nursing mother requires a medication, the drug should be tak...