Herbal product use and perioperative patients

AORN Journal, May, 2004 by Cheryl MacKichan, Jacklyn Ruthman

Guidelines for preoperative assessment and patient education about herbal products have been proposed. These include

* avoiding herbal remedies if nursing or pregnant;

* checking facts about herbal product claims with a qualified health care professional;

* discontinuing use of herbal products if any untoward effect or unusual symptom occurs and reporting this to a health care provider;

* discussing herbal product use with all health care providers;

* purchasing herbal products that have been standardized in terms of known effects for a given dose;

* reading the labels of herbal products carefully;

* using caution when giving herbal products to children and older adults; and

* using only recommended products that are labeled with the

* scientific name of the herb;

* manufacture date;

* expiration date;

* lot number;

* proof of adherence to good manufacturing practice (ie, standards established for food processing);

* proof that the product has undergone scientific testing; and

* the address of the supplier. (18) (p183)

Three research-based reports are available regarding herbal products and preoperative surgical patients. These reports are descriptive studies that used self-report questionnaires about herbal product use before surgery. The conclusions drawn from these research reports indicate that herbal product use among preoperative patients is common, with 22% to 73% of patients reporting alternative medicine use. (3-6) Herbal products may prolong coagulation time, affect blood pressure, act as a sedative, affect cardiac function, or affect electrolytes. (5) About 50% of patients report discontinuing use before surgery. (4) This implies that the other 50% did not discontinue herbal product use before surgery, putting them at risk for complications. Surgery was cancelled for one patient with prolonged clotting times who had taken ginkgo biloba for several weeks before surgery. (4)

Reasons cited by patients for taking herbal products include

* self-prescribed to improve general health,

* recommendation from a friend or family member, and

* recommendation of a health care provider or media sources. (4,6)

Understanding reasons for taking herbal products may help health care providers tailor preoperative teaching so patients understand the importance of reporting use and, in many instances, discontinuing use before surgery.

It is evident that herbal medicine research, as it relates to implications for perioperative patients, is just beginning. It is important for clinicians to understand how herbal products function and how herb-medication interactions affect the perioperative patient.

TABLE 1
Commonly Used Herbal Products

Herb                                            Perioperative
(Scientific name)      Indications for use      concerns/instructions

Echinacea (1-3)
(Echinacea             * Prevents and treats    * May cause allergic
angustifolio,            bacterial, viral,        reactions
E purpura, E pallida)    and fungal infections  * Decreases
                                                  effectiveness of
                                                  immunosuppressants
                                                * May cause
                                                  immunosuppression

Ephedra (1,4-6)
(Ephedra sinica,       * Increases energy       * May cause insomnia,
ma Huang)              * Acts as an appetite      tachycardia,
                         suppressant              headache,
                       * Acts as a                irritability,
                         bronchodilator           restlessness,
                                                  nausea, cardiac
                                                  arrhythmias,
                                                  myocardial
                                                  infarction, cardiac
                                                  arrest, seizure,
                                                  stroke, or death

Garlic (1-3,5,7)
(Allium sativum)       * Lowers cholesterol     * Inhibits platelet
                       * Reduces blood            aggregation
                         pressure and thrombus  * Prolongs bleeding
                         formation                and clotting times
                       * Acts as an             * Discontinue seven
                         antibacterial and        days before surgery
                         antimycotic

Ginkgo (1,3,5,6,8,9)
(Ginkgo biloba)        * Treats cognitive       * Decreases blood clot
                         disorders, peripheral    formation
                         vascular disease,      * Increases risk of
                         vertigo, and tinnitus    bleeding
                                                * Inhibits platelet
                                                  aggregation
                                                * Discontinue at least
                                                  36 hours before
                                                  surgery

Ginseng (1,3,6)
(Panax)                * Treats hemoptysis,     * Inhibits platelet
                         gastric disturbances,    aggregation
                         and vomiting           * Increases risk of
                       * Protects against         bleeding
                         stress                 * Causes hypoglycemia
                       * Combats weakness         and edema
                                                * Potential
                                                  interaction with
                                                  warfarin
                                                * Potential
                                                  interaction
                                                  with stimulants
                                                * May cause
                                                  hypertension or
                                                  tachycardia
                                                * Discontinue seven
                                                  days before surgery

Kava (1,5,10)
(Piper methysticum     * Acts as an             * Possibly potentiates
rhiszoma)                antispasmodic and        any substance that
                         anticonvulsant by its    affects the central
                         central muscle           nervous system (CNS)
                         relaxation effects       (ie, anesthetics,
                       * Causes hypnosis,         barbiturates,
                         sedation, and            benzodiazepines)
                         analgesia              * Discontinue at least
                       * Acts as a                24 hours before
                         psychotropic             surgery