402
Mayo CIiD Proc, April 1992, Vol 67
LETTERS
oxygenators and therefore recommended the use of membrane rather than bubble oxygenators. Finally, van der Linden and Casimir-Abu' monitored 10 patients who underwent open-heart surgical procedures and cardiopulmonary bypass by using membrane oxygenators without arterial filters to detect cerebral air emboli. Despite relatively rigorous attempts at deaerating, a 2-MHz pulsed transcranial Doppler ultrasound velocimeter that obtained signals of flow velocity from the middle cerebral artery detected emboli and showed that they were most numerous when the aortic cannula was inserted and when the empty, beating ventricle was filled. The investigators were also able to discern that aggressive deaerating maneuvers did decrease the amount of emboli. No neuropsychologic testing was performed on the patients involved in this study. Dr. van der Linden states that if monitoring is begun before cerebral air embolism occurs and if the embolus occurs in the monitored area, transcranial Doppler ultrasonography may indeed detect an embolus. If, however, the area where the cerebral air embolus occurs or flows to is not being monitored, the embolus will not be detected. Furthermore, background noise can hinder detection. Nonetheless, we appreciate and agree, in general, with the comments of Dr. van der Linden. Only by prospectively identifying the problem of gaseous cerebral air emboli and then randomizing animals to hyperbaric therapy (in animal models) or patients to conventional aggressive treatment (in clinical trials) can we determine the most appropriate manner to manage this potentially devastating complication of surgical intervention.
A. Joseph Layon, M.D. Departments of Anesthesiology and Medicine Michael E. Mahla, M.D. Departments of Anesthesiology and Neurosurgery University of Florida College of Medicine Gainesville, Florida REFERENCES 1. Spencer MP, Thomas 61, Nicholls SC, Sauvage LR: Detection of middle cerebral artery emboli during carotid endarterectomy using transcranial Doppler ultrasonography. Stroke 21:415423, 1990 2. Padayachee TS, Parsons S, Theobold R, Linley J, Gosling RG, Deverall PB: The detection of microemboli in the middle cerebral artery during cardiopulmonary bypass: a transcranial Doppler ultrasound investigation using membrane and bubble oxygenators. Ann Thorac Surg 44:298-302,1987
3. Van der Linden J, Casimir-Ahn H: When do cerebral emboli appear during open heart operations? A transcranial Doppler study. Ann Thorac Surg 51:237-241,1991
Surgical Bleeding Associated With Aspirin and Nonsteroidal Anti-Inflammatory Agents Intraoperative or postoperative blood loss associated with the use of aspirin or nonsteroidal anti-inflammatory agents rarely is life-threatening. Impaired coagulation, however, can compromise a surgical result, particularly with grafts, flaps, or microsurgical procedures. A single O:65-g dose of aspirin may increase the mean bleeding time of a normal person for 4 to 7 days, presumably because of the decreased formation of the platelet aggregation stimulator thromboxane Az. I Nonsteroidal anti-inflammatory drugs have a similar mechanism of action, although the duration of effect varies widely-from less than 1 day for flurbiprofen, ibuprofen, indomethacin, and sulindac to 2 weeks for piroxicam. z If medically appropriate, we ask our patients to discontinue taking any medications that contain aspirin or nonsteroidal anti-inflammatory agents at least 1 week before a planned surgical procedure. Many patients are unaware that these compounds are present in an astonishing array of products (Table 1).1.6 We hope that this information will be helpful to surgeons in preoperative discussions with patients. George B. Bartley, M.D. Department of Ophthalmology Roger A. Wamdahl, R.Ph. Mayo Pharmacy REFERENCES
1. lnsel PA: Analgesic-antipyretics and antiinflammatory agents: drugs employed in the treatment of rheumatoid arthritis and gout. In Goodman and Gilman's The Pharmacological Basis of Therapeutics. Eighth edition. Edited by AG Gilman, TW Rall, AS Nies, P Taylor. New York, Pergamon Press, 1990, p 647 2. USP DI. Vol IA: Drug Information for the Health Care Professional. Eleventh edition. Rockville, Maryland, United States Pharmacopeial Convention, 1991, P 484 3. McEvoy GK, Litvak K, McQuarrie GM, Schmadel LK (eds): AHFS Drug Information. Bethesda, Maryland, American Society of Hospital Pharmacists, 1991 4. Olin BR, Hebel SK, Connell si, Dombek CE (eds): Facts and Comparisons Loose-Leaf Drug Information Service. St. Louis, JB Lippincott Company, Facts and Comparisons Division, 1991 5. Physicians' Desk Reference. Forty-sixth edition. Oradell, New Jersey, Medical Economics Company, 1992 6. Davidson DE (ed): Handbook of Nonprescription Drugs. Eighth edition. Washington, DC, American Pharmaceutical Association, 1986
Mayo Clin Proc, April 1992, Vol 67
LETTERS
403
Table I.-Orally Administered Medications That Increase Bleeding Time
Preparations that contain aspirin or salicylic acid derivatives * Adult Analgesic Pain Reliever Alka-Seltzer Anacin Analval Anodynos APAC Improved Artha-G Arthritis Pain Formula Arthropan ASA Ascriptin Aspercin Aspergum Aspermin Aspirin with codeine AspirTab Asproject Axotal Azdone tablets B-A-C tablets Bayer aspirin Bayer children's cold tablets BCpowder BC tablets Buffaprin Buffasal Bufferin Buffets II Buffex Buffinol Cama arthritis pain reliever Carisoprodol compound tablets Children's aspirin Cope
Damason-P Darvon compound Darvon compound-65 Darvon with A.S.A. Darvon-N with A.S.A. Dasin Disalcid Diurex Doan's Dolcin Dolprn #3 tablets Drinophen Duradyne Easprin Ecotrin Emagrin Empirin Empirin with codeine Equagesic Equazine-M Excedrin Fiogesic tablets Fiorgen PF Fiorinal Fiorinal with codeine 4-W ay Cold tablets Gelpirin tablets Gemnisyn Genprin Gensan Goody's Extra Strength Goody's Headache Powder Infantol Pink Isollyl Improved
Lanorinal Lortab ASA Magan Magnaprin Magsal Marnal Measurin Meprobamate and aspirin Meprogesic Q Micrainin Midol for cramps, maximum strength Midol Original Mobidin Mobigesic Momentum muscular backache formula Mono-Gesic Neogesic Norgesic Norgesic Forte Norwich extra-strength aspirin Orphenagesic Orphenagesic Forte Oxycodone and aspirin Pabalate-SF P-A-C Pain reliever tablets Panodynes Pepto-Bismol Percodan Percodan-Demi Persistin Phenetroncompound
Presalin Propoxyphene compound Propoxyphene napsylate withASA Quiet W orId tablets Rexolate Robaxisal tablets Roxiprin tablets St. Joseph Salabuff Salatin Saleto Salflex Salicylamide Salocol Salsalate Salsitab Sine-Off sinus medicine tablets Soma compound tablets Soma compound with codeine Stanback Powder Supac Synalgos-DC capsules Talwin compound Tenol-Plus Trigesic Trilisate Tri-Pain Tusal Ursinus Inlay-Tabs Valesin Vanquish Verin Wesprin Buffered Zorprin
Preparations that contain nonsteroidal anti-inflammatory agentsi Aches-N-Pain (ibuprofen) Addaprin (ibuprofen) Advil (ibuprofen) Anaprox (naproxen sodium) Anaprox DS (naproxen sodium) Ansaid (flurbiprofen) Butazolidin (phenylbutazone) Clinoril (sulindac) CoAdvil (ibuprofen)
Dolobid (diflunisal) Dristan Sinus (ibuprofen) Feldene (piroxicam) Genpril (ibuprofen) Haltran (ibuprofen) IBU (ibuprofen) IBU-TAB (ibuprofen) Ibuprin (ibuprofen) Ibuprohm (ibuprofen)
*ASA = acetylsalicylic acid. tThe trade names are followed by the generic names in parentheses.
Indocin (indomethacin) Lodine (etodolac) Medipren (ibuprofen) Menadol (ibuprofen) Midol 200 (ibuprofen) Motrin (ibuprofen) Motrin IB (ibuprofen) Nalfon (fenoprofen calcium) Naprosyn (naproxen) Nuprin (ibuprofen)
Orudis (ketoprofen) Pamprin-IB (ibuprofen) PediaProfen (ibuprofen) Rufen (ibuprofen) Saleto-200 (ibuprofen) Tolectin (tolmetin sodium) Trendar (ibuprofen) Ultraprin (ibuprofen) Unipro (ibuprofen) Valprin (ibuprofen)
Mayo CIiD Proc, April 1992, Vol 67
LETTERS
oxygenators and therefore recommended the use of membrane rather than bubble oxygenators. Finally, van der Linden and Casimir-Abu' monitored 10 patients who underwent open-heart surgical procedures and cardiopulmonary bypass by using membrane oxygenators without arterial filters to detect cerebral air emboli. Despite relatively rigorous attempts at deaerating, a 2-MHz pulsed transcranial Doppler ultrasound velocimeter that obtained signals of flow velocity from the middle cerebral artery detected emboli and showed that they were most numerous when the aortic cannula was inserted and when the empty, beating ventricle was filled. The investigators were also able to discern that aggressive deaerating maneuvers did decrease the amount of emboli. No neuropsychologic testing was performed on the patients involved in this study. Dr. van der Linden states that if monitoring is begun before cerebral air embolism occurs and if the embolus occurs in the monitored area, transcranial Doppler ultrasonography may indeed detect an embolus. If, however, the area where the cerebral air embolus occurs or flows to is not being monitored, the embolus will not be detected. Furthermore, background noise can hinder detection. Nonetheless, we appreciate and agree, in general, with the comments of Dr. van der Linden. Only by prospectively identifying the problem of gaseous cerebral air emboli and then randomizing animals to hyperbaric therapy (in animal models) or patients to conventional aggressive treatment (in clinical trials) can we determine the most appropriate manner to manage this potentially devastating complication of surgical intervention.
A. Joseph Layon, M.D. Departments of Anesthesiology and Medicine Michael E. Mahla, M.D. Departments of Anesthesiology and Neurosurgery University of Florida College of Medicine Gainesville, Florida REFERENCES 1. Spencer MP, Thomas 61, Nicholls SC, Sauvage LR: Detection of middle cerebral artery emboli during carotid endarterectomy using transcranial Doppler ultrasonography. Stroke 21:415423, 1990 2. Padayachee TS, Parsons S, Theobold R, Linley J, Gosling RG, Deverall PB: The detection of microemboli in the middle cerebral artery during cardiopulmonary bypass: a transcranial Doppler ultrasound investigation using membrane and bubble oxygenators. Ann Thorac Surg 44:298-302,1987
3. Van der Linden J, Casimir-Ahn H: When do cerebral emboli appear during open heart operations? A transcranial Doppler study. Ann Thorac Surg 51:237-241,1991
Surgical Bleeding Associated With Aspirin and Nonsteroidal Anti-Inflammatory Agents Intraoperative or postoperative blood loss associated with the use of aspirin or nonsteroidal anti-inflammatory agents rarely is life-threatening. Impaired coagulation, however, can compromise a surgical result, particularly with grafts, flaps, or microsurgical procedures. A single O:65-g dose of aspirin may increase the mean bleeding time of a normal person for 4 to 7 days, presumably because of the decreased formation of the platelet aggregation stimulator thromboxane Az. I Nonsteroidal anti-inflammatory drugs have a similar mechanism of action, although the duration of effect varies widely-from less than 1 day for flurbiprofen, ibuprofen, indomethacin, and sulindac to 2 weeks for piroxicam. z If medically appropriate, we ask our patients to discontinue taking any medications that contain aspirin or nonsteroidal anti-inflammatory agents at least 1 week before a planned surgical procedure. Many patients are unaware that these compounds are present in an astonishing array of products (Table 1).1.6 We hope that this information will be helpful to surgeons in preoperative discussions with patients. George B. Bartley, M.D. Department of Ophthalmology Roger A. Wamdahl, R.Ph. Mayo Pharmacy REFERENCES
1. lnsel PA: Analgesic-antipyretics and antiinflammatory agents: drugs employed in the treatment of rheumatoid arthritis and gout. In Goodman and Gilman's The Pharmacological Basis of Therapeutics. Eighth edition. Edited by AG Gilman, TW Rall, AS Nies, P Taylor. New York, Pergamon Press, 1990, p 647 2. USP DI. Vol IA: Drug Information for the Health Care Professional. Eleventh edition. Rockville, Maryland, United States Pharmacopeial Convention, 1991, P 484 3. McEvoy GK, Litvak K, McQuarrie GM, Schmadel LK (eds): AHFS Drug Information. Bethesda, Maryland, American Society of Hospital Pharmacists, 1991 4. Olin BR, Hebel SK, Connell si, Dombek CE (eds): Facts and Comparisons Loose-Leaf Drug Information Service. St. Louis, JB Lippincott Company, Facts and Comparisons Division, 1991 5. Physicians' Desk Reference. Forty-sixth edition. Oradell, New Jersey, Medical Economics Company, 1992 6. Davidson DE (ed): Handbook of Nonprescription Drugs. Eighth edition. Washington, DC, American Pharmaceutical Association, 1986
Mayo Clin Proc, April 1992, Vol 67
LETTERS
403
Table I.-Orally Administered Medications That Increase Bleeding Time
Preparations that contain aspirin or salicylic acid derivatives * Adult Analgesic Pain Reliever Alka-Seltzer Anacin Analval Anodynos APAC Improved Artha-G Arthritis Pain Formula Arthropan ASA Ascriptin Aspercin Aspergum Aspermin Aspirin with codeine AspirTab Asproject Axotal Azdone tablets B-A-C tablets Bayer aspirin Bayer children's cold tablets BCpowder BC tablets Buffaprin Buffasal Bufferin Buffets II Buffex Buffinol Cama arthritis pain reliever Carisoprodol compound tablets Children's aspirin Cope
Damason-P Darvon compound Darvon compound-65 Darvon with A.S.A. Darvon-N with A.S.A. Dasin Disalcid Diurex Doan's Dolcin Dolprn #3 tablets Drinophen Duradyne Easprin Ecotrin Emagrin Empirin Empirin with codeine Equagesic Equazine-M Excedrin Fiogesic tablets Fiorgen PF Fiorinal Fiorinal with codeine 4-W ay Cold tablets Gelpirin tablets Gemnisyn Genprin Gensan Goody's Extra Strength Goody's Headache Powder Infantol Pink Isollyl Improved
Lanorinal Lortab ASA Magan Magnaprin Magsal Marnal Measurin Meprobamate and aspirin Meprogesic Q Micrainin Midol for cramps, maximum strength Midol Original Mobidin Mobigesic Momentum muscular backache formula Mono-Gesic Neogesic Norgesic Norgesic Forte Norwich extra-strength aspirin Orphenagesic Orphenagesic Forte Oxycodone and aspirin Pabalate-SF P-A-C Pain reliever tablets Panodynes Pepto-Bismol Percodan Percodan-Demi Persistin Phenetroncompound
Presalin Propoxyphene compound Propoxyphene napsylate withASA Quiet W orId tablets Rexolate Robaxisal tablets Roxiprin tablets St. Joseph Salabuff Salatin Saleto Salflex Salicylamide Salocol Salsalate Salsitab Sine-Off sinus medicine tablets Soma compound tablets Soma compound with codeine Stanback Powder Supac Synalgos-DC capsules Talwin compound Tenol-Plus Trigesic Trilisate Tri-Pain Tusal Ursinus Inlay-Tabs Valesin Vanquish Verin Wesprin Buffered Zorprin
Preparations that contain nonsteroidal anti-inflammatory agentsi Aches-N-Pain (ibuprofen) Addaprin (ibuprofen) Advil (ibuprofen) Anaprox (naproxen sodium) Anaprox DS (naproxen sodium) Ansaid (flurbiprofen) Butazolidin (phenylbutazone) Clinoril (sulindac) CoAdvil (ibuprofen)
Dolobid (diflunisal) Dristan Sinus (ibuprofen) Feldene (piroxicam) Genpril (ibuprofen) Haltran (ibuprofen) IBU (ibuprofen) IBU-TAB (ibuprofen) Ibuprin (ibuprofen) Ibuprohm (ibuprofen)
*ASA = acetylsalicylic acid. tThe trade names are followed by the generic names in parentheses.
Indocin (indomethacin) Lodine (etodolac) Medipren (ibuprofen) Menadol (ibuprofen) Midol 200 (ibuprofen) Motrin (ibuprofen) Motrin IB (ibuprofen) Nalfon (fenoprofen calcium) Naprosyn (naproxen) Nuprin (ibuprofen)
Orudis (ketoprofen) Pamprin-IB (ibuprofen) PediaProfen (ibuprofen) Rufen (ibuprofen) Saleto-200 (ibuprofen) Tolectin (tolmetin sodium) Trendar (ibuprofen) Ultraprin (ibuprofen) Unipro (ibuprofen) Valprin (ibuprofen)
