CORRESPONDENCE

among whom coagulopathy is Levels of inflammatory markers in the blood 2 Grant ECG. The pill, hormone replacement
common. Any reduction in short-term processed by autotransfusion devices during therapy, vascular and mood over-reactivity
cardic surgery associated with and mineral imbalance. J Nutr Environ Med
morbidity produced by epidural 1998; 8: 105–16.
cardiopulmonary bypass circuit. Perfusion
analgesia would be outweighed by even 2002; 17: 117–23. 3 Anon. Further analyses of mortality in oral
a low rate of paraplegia. However, the contraceptive users: Royal College of
risk of haematoma should be minimal General Practitioners’ Oral Contraception
in patients undergoing off-pump Study. Lancet 1981; 1: 541–46.
Avoid hormones in 4 Incidence of arterial disease among oral
CABG surgery, since they receive only
small amounts of heparin and are gastrointestinal contraceptive users: Royal College of
General Practitioners’ Oral Contraception
unlikely to develop a coagulopathy. angiodysplasia Study. J R Coll Gen Pract 1983; 33:
The combination of epidural analgesia 75–82.
with off-pump surgery might, Sir—Humphrey Hodgson (May 11, 5 Irey NS, Manion WC, Taylor HB. Vascular
lesions in women taking oral contraceptives.
therefore, show even greater reductions p 1630)1 asks whether there is any Arch Pathol 1970; 89: 1–9.
in short-term morbidity. reason for exposing patients with
Another reason for caution when gastrointestinal angiodysplasia to the
interpreting studies comparing off- potential morbidities of oestrogen
pump with on-pump CABG surgery is therapy. There are good reasons for not Opioid prescription in
the concept that cardiopulmonary prescribing hormones. Italy: new law, no effect
bypass is one uniformly malevolent In a randomised controlled trial and
entity. In reality, equipment and a cohort study, no benefit was reported Sir—It is estimated that millions of
techniques differ vastly. One pertinent from oestradiol and norethisterone use, patients with cancer worldwide
part is the salvage of blood from the in contrast to a very small short trial in experience moderate to severe cancer
pericardial cavity to limit the need for which patients had lower transfusion pain. Unrelieved cancer pain
transfusion through activation of the requirements. continues to be a major public-health
coagulation and inflammatory systems. It is unsurprising that giving concern, despite available treatment.
Moreover, the blood contains hormones to patients with bleeding The use of opioids is the cornerstone
microparticles and lipid emboli that are results in confusion. In studies of the of cancer-pain management. Mis-
returned to the patient and could cause vascular changes in endometrial blood guided national health policies, non-
adverse outcomes such as cognitive vessels caused by a large range of availability of drugs, and inadequate
decrements.4 Therefore, cardiopulmo- progestagens and oestrogens, I found education of physicians and the public
nary bypass in itself may not be a cause that commonly used combinations are the main barriers to the
of adverse outcome after on-pump of these two hormones caused prescription of opioids. The trend of
CABG surgery, but rather a peripheral abnormalities in arterioles, sinusoids, increasing medical use of opioids to
technique such as pericardial salvage, or both. At the same time, lowered zinc treat pain does not seem to be
and excluding or washing blood from and raised copper concentrations contributing to increases in
this source might reduce them.5 interfere with immune system the health consequences of opioid
Clearly, Angelini and colleagues regulation that can raise the risk of analgesic abuse.1
show off-pump CABG surgery to be a gastrointestinal infections.2 In many European countries,
practical technique. However, its The large Royal College of General governments and legislators have been
advocacy, especially for sick elderly Practitioners’ Oral Contraceptive restrictive about the use of opioids.2 In
people, should be tempered until the Study3 shows increases in a wide range Italy, restrictive prescribing regulations
long-term cardiac outcome is known to of infections and vascular diseases after emerged as the most important barrier
be similar to that for on-pump CABG hormone treatment. The increased to adequate pain management by
surgery—97% graft patency at 15 years relative risk of death from vascular family physicians.3 In February, 2001,
after surgery. disease among ever users was 4·2, the Italian government approved a law
R Peter Alston which rose with age and smoking to aimed at facilitating opioid
Department of Anaesthesia, Critical Care and 7·4. Current users also had a significant prescription for cancer pain. It seems
Pain Medicine, Royal Infirmary of Edinburgh, 60% increase in diseases of the arteries, less restrictive and would potentially
Edinburgh EH3 9YW, UK arterioles, and capillaries.4 Abnormal have improved the prescription.
(e-mail: [email protected])
abdominal, hepatic, pulmonary, and We calculated, for the existing
leg blood vessels have been noted in opioids commercially available in Italy
1 Angelini GD, Taylor FC, Reeeves BC, women taking hormones for less than used mostly for cancer pain, the
Ascione R. Early and midterm outcome
5 years.5 amount sold 6 months before approval
after off-pump and on-pump surgery in
Beating Heart Against Cardioplegic Arrest The taking of female sex hormones of the new law and 6 months after, to
Studies (BHACAS 1 and 2): a pooled can increase the risk of vascular assess changes in the attitudes of
analysis of two randomised controlled trials. diseases, thrombosis with possible Italian physicians in prescribing
Lancet 2002; 359: 1194–99.
secondary haemorrhages, and opioids. Data are presented in the
2 Alston RP. Off-pump coronary artery
surgery and the brain. Br J Anaesth 2000; infections, which can also increase the table. Morphine has been marketed as
84: 549–52. risk of bleeding. Use of such hormones a slow-release preparation by two
3 Scott NB, Turfrey DJ, Ray DAA, et al. A for bleeding disorders, including
prospective randomized study of the hereditary haemorrhagic telangiectasia, Before After
potential benefits of thoracic epidural
therefore, does not seem sensible. Opioids 0·22 0·22
anesthesia and analgesia in patients
undergoing coronary artery bypass grafting. Ellen C G Grant Transdermal fentanyl 0·0005 0·0054
Anesth Analg 2001; 93: 528–35. 20 Coombe Ridings, Kingston-upon-Thames, Morphine 1* 0·1904 0·0074
4 Brooker RF, Brown WR, Moody DM, et al. Surrey KT2 7JU, UK Morphine 2* 0·0240 0·1785
Cardiotomy suction: a major source of brain (e-mail: [email protected]) *From two different anonymised companies.
lipid emboli during cardiopulmonary
bypass. Ann Thorac Surg 1998; 65: 1651–55. 1 Hodgson H. Hormonal therapy for
Opioid use in mg per person in general
5 Amand T, Pincemail J, Blaffart F, gastrointestinal angiodysphasia. Lancet population sold before and after change
Larbuisson R, Limet R, Defraigne JO. 2002; 359: 1630–31. in opioid prescription law

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