As the use of herbal supplements becomes more widespread, it is vitally important that the anesthetist has a detailed understanding of potential interactions with anesthetic medications and full knowledge of the perturbations these herbal remedies can have on patient physiology in a perioperative setting. The first question to ask after reviewing conventional medications is: “Do you take any herbal supplements/medications that are not documented in your chart? It may have an impact on your surgery and/or anesthetic.” The caveat is that patients do not always know to report supplements as medications. They may not understand the scope of properties these supplements have when not discontinued before surgery, especially when they will be exposed to a number of different medications during the perioperative and postsurgical course. A common recommendation is to refrain from taking herbal remedies for at least 2 weeks prior to surgery. This recommendation is not standard or widespread, and it is impossible to enforce due to noncompliance or emergency surgical situations. A pertinent, concise description is valuable to enhance understanding of these herbal remedies and avoid catastrophic outcomes due to inadequate consideration of these drugs effects. What follows is a review of few of the more commonly prescribed supplements that influence anesthetic drug action. A summary of these herbal remedies is presented in Table 13–1.
Summary of clinical effects, mechanisms of action, and anesthetic implication of selected herbal remedies.
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Table 13–1 Summary of clinical effects, mechanisms of action, and anesthetic implication of selected herbal remedies.
|Herbal Remedy ||Clinical Effects ||Mechanism of Action ||Anesthetic Implications |
Garlic (Allium sativum)
Source: Bulb from onion-like garlic plant
Decreased blood pressure
Decreased thrombus formation
|Dose-dependent platelet aggregation inhibition || |
Increased risk of bleeding
Possible potentiation of other platelet aggregation inhibitors
Echinacea (Echinacea purpurea)
Source: Coneflower, a flower from the daisy plant family
Immune system stimulant
Prophylaxis/treatment of viral, bacterial and fungal infections, particularly upper respiratory infections
|Unknown, may increase l-dopa levels || |
Consider avoiding in patients who require immunosuppression
Consider avoiding when coadministered with other potential hepatotoxic drugs
Valerian (Valeriana officinalis)
Source: Valerian root
|Potentiates GABA-ergic system || |
May potentiate benzodiazepines, opioids, and sedative hypnotics
May cause withdrawal postoperatively with abrupt cessation
Ephedra (ma huang)
Source: Ephedra plant
|α-1-, β-1-, and β-2-receptor agonism || |
Fatal cardiovascular events (myocardial infarct, stroke, death)
Perioperative hemodynamic instability
Adverse cardiovascular effects when mixed with MAOIs
Ginkgo (Ginkgo biloba)
Source: Leaf of ginkgo plant
Improved cognitive function
Inhibitor of platelet activation
Altered vascular tone
|Partially understood; flavonoids, terpenoids, and organic acids protect from oxidative damage. ||Rare postoperative bleeding |
St. John's wort: (Hypericum perforatum)
Source: Shrub plant of the same name containing hypericin and hyperforin
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