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Herbal Medicine and Anesthesia

Herbal Medicine and Anesthesia. Hsin -Wei Yang “Claire”, RN, B.S.N. Duke Nurse Anesthesia Class of 2013. Objectives. Discuss types of complementary and alternative medicine (CAM) Review herbal medicine regulations

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Herbal Medicine and Anesthesia

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  1. Herbal Medicine and Anesthesia Hsin-Wei Yang “Claire”, RN, B.S.N. Duke Nurse Anesthesia Class of 2013

  2. Objectives • Discuss types of complementary and alternative medicine (CAM) • Review herbal medicine regulations • Discuss common herbal medicines with basic pharmacology and anesthesia considerations • Case reports

  3. Why this topic? • The use of over-the-counter “natural” products is more popular in the United States • General public consider herbal medicine “natural and safe”. • 2007 National Health Statistics Report: ✓30% of adult surgical pt take herbal supplements ✓70% do not report to health care providers

  4. What is complementary and alternative medicine (CAM) ? • Difficult to define, because the field is very broad • and constantly changing • Complementary = used together with conventional • medicine (acupuncture + physical therapy) • Alternative = used in place of conventional • medicine National Center for Complementary and Alternative Medicine

  5. Types of CAM

  6. What is herbal medicine? • Refers to using a plant’s seeds, berries, roots, barks, or flowers for medical purposes • Contains plant materials as their pharmacologically active components

  7. The surge in herbal medicine • Used for medical purpose long before recorded history • Ancient Chinese and Egyptian describe medicinal uses from plants • African and Native American: healing rituals • People in different parts of the world tended to use the same or similar plants for the same purposes.

  8. The surge in herbal medicine • In the early 19th century, when chemical analysis first became available, scientists began to extract and modify the active ingredients from plants. • Later, chemists began to make their own version of plant compounds, and over time, the use of herbal medicines declined in favor of drugs • In the last 20 years in the United States, public dissatisfaction with the cost of prescription medications, combined with an interest in returning to natural or organic remedies, has let to an increase in herbal medicine use.

  9. Objectives • Discuss types of complementary and alternative medicine (CAM) • Review herbal medicine regulations • Discuss common herbal medicines with basic pharmacology and anesthesia considerations • Case reports

  10. How are herbal supplement regulated? Dietary Supplement Health and Education Act of 1994 • Herbals are considered dietary supplement and regulated as foods, not drugs • FDA regulate herbal medicine under a set of regulations that are different from those covering prescription and OTC medications

  11. How are herbal supplement regulated? • Do not need approval by FDA for effectiveness before marketing • FDA cannot remove herbal medicines from the market unless they prove it unsafe • Require the manufacturers to report all serious adverse event to FDA • Manufacturer must comply with Dietary Supplement Current Good Manufacturing Practice to ensure identity, purity, quality, strength and composition of the herbals

  12. Labels Must Include: • Descriptive name of the product stating that it is a “supplement” • Name and place of business of the manufacturer • Complete list of ingredients; Net content of the product • “…not intended to diagnose, treat, cure or prevent any diseases.”

  13. Objectives • Discuss types of complementary and alternative medicine (CAM) • Review herbal medicine regulations • Discuss common herbal medicines with basic pharmacology and anesthesia implications • Case reports

  14. 1. Ephedra (Ma Huang: 麻黃） • Common use: asthma and bronchitis • In the Western World: enhance athletic performance, “fat burning”, and weight loss • Sympathomimetic precursor to ephedrine, pseudoephedrine, methylephedrine, and norpseudo-ephedrine. • MOA: α and β adrenergic agonists

  15. Ephedra: Adverse Effects • Hypertension • Tachycardia & Cardiac arrhythmias • MI • Stroke • Banned for sale as supplement by FDA in April 2004 • Still available online

  16. Ephedra: Anesthesia Implications • Potentially interact with volatiles ( Desflurane and Isoflurane) and Digitalis to cause cardiac dysarrhythmias • Patients taking Ephedra for prolonged periods of time can deplete peripheral catecholamine stores • Avoid use with Oxytocin sever hypertension

  17. 2. Ginkgo 銀杏 • Common use: improves memory, peripheral vascular dx • Best selling herbs in the United States in 1997 • MOA: antioxidant, inhibits platelet activating factor • Also decreases erythrocyte aggregation and blood viscosity

  18. Ginkgo: Adverse Effects • Bleeding • Antiplatelet effects are dose dependent, long-lasting, and rapidly established after oral intake • Case reports of spontaneous intracranial bleeding and postop bleeding from laparoscopic surgery

  19. Gingko: Case Report

  20. 34 years old Africa American male • C/O 3 weeks history of RUQ pain with N/V • Dx: Cholelithiasislaparoscopic cholecystectomy • No past medical hx and denies taking any medications • Preop labs: unremarkable, Hgb 16.5 g/dL, Plt 217 • Intraop: uneventful, JP drain was placed for possible bile leakage from an inflamed liver surface

  21. POD #1: JP drain with 65ml serosanginous fluid Hgb 12.4 g/dL • POD #2: JP drain with 300ml bloody fluid Hgb 5.4 g/dL • Received 2 units of FFP and 2 PRBCs, Hgbto 8.0 g/dL Pt remained hemodynamically stable • Upon further questioning, the pt admitted to take 2 tablets of Gingko per day for years

  22. Gingko: Anesthesia Implications • Augment the effect of Coumadin, Heparin, NSAIDs, and Aspirin, result in increased risk for intraop or postop bleeding • ✗use with anticonvulsant b/c Gingko will decrease the effectiveness

  23. 3. Garlic 大蒜 • Common use: reduce blood pressure, lower cholesterol • Modify the risk of developing atherosclerosis • MOA: irreversible inhibition of platelet aggregation in a dose-dependent manner, occurs within 5 days of oral intake

  24. Garlic: Adverse Effects • Nausea/Vomiting • Hypotension • Rose et al. reported a case of spontaneous spinal-epidural hematoma causing paraplegia in a 87 year old man, with associated platelet dysfunction related to excessive garlic ingestion

  25. Garlic: Anesthesia Implications • Same as Gingko • Augment the effect of Coumadin, Heparin, NSAIDs, and Aspirin, result in increased risk for intraop or postop bleeding • Avoid in Diabetic patients: potentiate hypoglycemic effects of anti-diabetic agents

  26. 4. Ginger 薑 • Common use: nausea, vomiting, motion sickness • MOA: suppress gastric contractions potent thromboxane synthetase inhibitor • Prolonged or heavy use of ginger has been reported to affect platelet aggregation • Anesthesia implication: same as Gingko and Garlic

  27. 5. Ginseng 人蔘 • Common use: enhance performance, blood glucose • MOA: CNS stimulation, also inhibit platelet aggregation • Adverse effects: hypertension, nervousness, insomnia • Weak estrogenic properties vaginal bleeding • Anesthesia implications: same as Gingko, Garlic, Ginger

  28. Take Home Message Herbal supplements that increase risk of bleeding are? Gingko Garlic Ginger Ginseng

  29. 6. Kava kava 卡瓦卡瓦 • Common use:  anxiety • MOA: bind to GABA receptors • Anesthesia implications: potentiate the effect of barbiturates or benzodiazepines, causing excessive sedation • Suspended in 2002 following reports of fatal liver toxicities

  30. 7. Valerian • Common use: sleep aid for insomnia • MOA: binds to GABA receptors • Anesthesia implications: • same as Kava kava + benzo like withdraw symptoms + taper dose weeks before surgery

  31. 8. St. Johns Wort • Common use: treat depression (the herb of happiness) • MOA: inhibits serotonin reuptake inhibits monoamine oxidase (MAO) inhibits GABA receptors  antidepressant effect

  32. St. John’s Wort: Adverse Effects • Enzyme induction: CYP 3A4 (subtype of P450) • Affect the effectiveness of oral contraceptives, theophylline [thee-off-i-lin], midazolam, lidocaine, calcium channel blockers •  Serum Cyclosporine levels •  Serum Warfarin, Digoxin levels

  33. St. John’s Wort: Case Report

  34. St. John’s Wort: Case Report • 61 year old pt admitted for elective endomyocardial biopsy • S/P heart transplant 11 months ago • Maintained on triple immunosupressive regimen: cyclosporin, imuran, and corticosteriods • Self-medicated with St. John’s Wort for depression 3 weeks prior biopsy

  35. St. John’s Wort: Case Report • Biopsy showed acute cellular transplant rejection • Labs: normal, except  cyclosporin blood concentrations (below therapeutic range) • St. John’s Wort d/c’d immediately + Cyclosporin dosage was increased + IV corticosteroid bolus • Plasma cyclosporin reached therapeutic range and no further episode of rejection

  36. St. John’s Wort: Anesthesia Implications • Not recommended to use it with MAOI’s and SSRI’s • Should be stopped at lease 5 days prior surgery and discontinued postop • Especially for patients require anticoagulation or immunosupression

  37. Summary • Natural ≠ safe or no harm • Remember to ask about herbal remedy use • Should stop herbal use 2 weeks prior surgery • Herbals may act at similar receptor sites as anesthetics or prescription drugs and result in significant clinical effects

  38. Summary • With respect to anesthesia, herbals can cause CV side-effects(Ephedra) Bleeding(4 G’s) Prolonged anesthesia (Kava Kava, Valarian) Organ transplant rejection (St. John’s Wort)

  39. Questions?

  40. References • Ang-Lee, M. K., Moss, J., & Yuan, C. S. (2001). Herbal medicines and perioperative care. JAMA, 286(2), 208-216. • Cheng, B., Hung, C. T., & Chiu, W. (2002). Herbal medicine and anaesthesia. [Review]. Hong Kong Med J, 8(2), 123-130. • Fessenden, J. M., Wittenborn, W., & Clarke, L. (2001). Gingko biloba: a case report of herbal medicine and bleeding postoperatively from a laparoscopic cholecystectomy. [Case Reports]. Am Surg, 67(1), 33-35. • Hodges, P. J., & Kam, P. C. (2002). The peri-operative implications of herbal medicines. Anaesthesia, 57(9), 889-899. • Kaye, A. D., Kucera, I., & Sabar, R. (2004). Perioperative anesthesia clinical considerations of alternative medicines. AnesthesiolClin North America, 22(1), 125-139.

  41. References • Kuczkowski, K. M. (2006). Labor analgesia for the parturient with herbal medicines use: what does an obstetrician need to know? Arch GynecolObstet, 274(4), 233-239. • Norred, C. L., Zamudio, S., & Palmer, S. K. (2000). Use of complementary and alternative medicines by surgical patients. AANA J, 68(1), 13-18. • Pribitkin, E. (2005). Herbal medicine and surgery. Seminars in Integrative Medicine, 3(1), 17-23 • Ruschitzka, F., Meier, P. J., Turina, M., Luscher, T. F., & Noll, G. (2000). Acute heart transplant rejection due to Saint John's wort. Lancet, 355(9203), 548-549.

  42. 2013 When was the Declaration of Independence adopted? • July 4, 1776 • July 4, 1789 • December 7, 1787 • March 4, 1789 To Be Continued……

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