HERBAL MEDICINES ANESTHETIC IMPLICATIONS

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HERBAL MEDICINESANESTHETIC IMPLICATIONS

• M. Ron Eslinger
• CRNA, MA, APN
• www.aamsn.com

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• A 35 year old athletic woman with a history of
  migraines presents for ACL reconstruction. Her
  only pertinent history is previous PONV after 3
  GAs for gynecologic procedures. She completed a
  preop screening form and consultation in the
  preop clinic was deferred. She indicates
  multivitamin use on her questionnaire.
• She is very motivated to avoid PONV this time.

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• A 35 year old otherwise healthy mother of three
  presents for posterior lumbar fusion for chronic
  back pain that has failed conservative treatment.
  Because of her unremarkable history, her
  consultation in preop clinic was deferred. She is
  attended by her mother as she and her spouse are
  separated.

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A 35 year old athletic woman with a history of
migraines presents for ACL reconstruction.
History of PONV.

• Feverfew
• Ginger

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35 year old for posterior spinal fusion.

• St. Johns Wort

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HERBAL MEDICINEHISTORY

• Early archaeological evidence - Neanderthal
• 16th Century Medicinal Plants
• Scientific method and the marginalization of
  Herbal Medicine - 19th Century
• Rebirth of herbal medicine and natural health in
  the 1960s
• Establishment of Office of Alternative Medicine,
  National Institutes of Health 1992
• 1994 FDA Dietary Supplement and Health Education
  Act

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HERBAL MEDICINEEPIDEMIOLOGY

• 3 - 93 of U.S. population use herbals
• Generally higher internationally

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Tsen, et al, Alternative medicine Use in
Presurgical Patients, Anesthesiology, 93, 148-51

• Incidence of Herbal Medicine Use Among Age Groups
• Age group

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Tsen, et al, Alternative medicine Use in
Presurgical Patients, Anesthesiology, 93, 148-51

• n3106

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Top Ten Selling Herbs1995 Survey of 163 Health
Food Retail Stores(Winslow and Kroll, 1998)

• ECHINACEA
• GARLIC
• GOLDENSEAL
• GINSENG
• GINKGO
• SAW PALMETTO
• ALOE
• MA HUANG
• SIBERIAN GINSENG
• CRANBERRY
• (ST. JOHNS WORT, VALERIAN, FEVER FEW)

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ECONOMICS AND REIMBURSEMENT

• 553 million in 8000 health food stores - 1994
• 1.2 billion from all sources
• 20 annual growth rate
• largest growth area in retail pharmacies
• increasing coverage of herbals and alternative
  therapies by insurance and managed care industries

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QUALITY CONTROL

• 1994 Dietary Supplement and Health Education Act
• Compromise act
• No requirements for
• Proof of efficacy
• Proof of safety
• Standards for quality control
• Cannot promise a specific cure, but may claim
  effect
• Burden of proving product unsafe lies with FDA

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QUALITY CONTROL

• Variability between manufactures and batches
• Potency affected by growing conditions, storage,
  handling, and preparation - up to 10,000 fold
  difference in potency

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QUALITY CONTROL

• Inaccuracy of labels
• Contamination with other substances
• Mandrake(scopolamine) or Snakeroot (reserpine) in
  Ginseng preparations
• Use of additives not found on label (NSAIDs,
  steroids, antibiotics, sedatives, hypnotics)
• Belladonna poisoning in herbal tea (NYC)
• Digitalis intoxication from mislabeled plant
  extract
• Heavy metals (lead, arsenic, cadmium, copper,
  mercury) in preparations from some foreign
  countries

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EFFICACY AND SAFETY

• No profit in conducting controlled studies in
  U.S.
• Reported effects stem from anecdotal reports and
  a few well controlled clinical trials
• System for reporting ADRs for herbals and
  dietary supplements is poor (FDA web site
  available at http//www.fda.gov
• Potential safety issues include
• Drug-herb interactions
• Herb-body interactions (inhibition or stimulation
  of microsomal liver enzymes)
• Toxicity from contaminants
• Delayed intervention with allopathic treatment

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ORGAN SYSTEM TOXICITY(from Winslow and Kroll,
1998)

• GASTROINTESTINAL
• HEPATOTOXIC (MILD TO SEVERE)
• Chinese herbal teas, Mistletoe, Germander,
  Chaparral, Comfrey
• NAUSEA/VOMITTING
• Dandelion, Garlic, Ginseng, Chaparral
• DIARRHEA
• Herbal teas, Aloe, Ligustrum, Dandelion,
  Prunelia, Garlic, Ginseng
• HEMATOLOGIC
• ANTICOAGULANT/ANTIPLATELET
• Yarrow, Red clover, Tang-kuei, Pau darco, Salvia

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ORGAN SYSTEM TOXICITY(from Winslow and Kroll,
1998)

• CENTRAL NERVOUS SYSTEM
• NERVOUSNESS / AGITATION/INSOMNIA / MOOD CHANGES
• DEPRESSION / CONFUSION / HALLUCINATIONS
• Ginseng (long-term and higher doses)
• HALLUCINOGENIC
• Catnip, Hops, Kava kava, Khat, Lobelia, Mandrake,
  Nutmeg, Jimson weed, Valerian, Yohimbe
• CHOLINERGIC TOXICITY
• (CONTAINS ATROPINE, SCOPOLOMINE, HYOSCYAMINE)
• Jimson weed
• SEDATION
• Peony, Salvia, Tang-kuei
• SEIZURES / PSYCHOSIS / COMA
• Ephedra

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ORGAN SYSTEM TOXICITY(from Winslow and Kroll,
1998)

• PULMONARY
• PULMONARY HYPERTENSION
• Chinese herbal teas
• ALLERGIC / IMMUNOLOGIC
• CONTACT DERMATITIS
• Propolis, Garlic, Echinacea, Melaleuca oil
• SYSTEMIC LUPUS ERYTHEMATOSIS
• Alfalfa
• RENAL
• DIURESIS
• Burdock, Astragalus, Peony, Dandelion
• HYPERTENSION / SODIUM AND WATER RETENTION /
  HYPOKALEMIA
• Licorice, Glycyrrhiza glabra, Glycyrrhiza radix

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ORGAN SYSTEM TOXICITY(from Winslow and Kroll,
1998)

• ENDOCRINOLOGIC
• GYNECOMASTIA / VAGINAL BLEEDING
• Ginseng (estrogen-containing)
• GOITERS / HYPERTHYROIDISM / HYPOTHYROIDISM
• Kelp (iodine-containing)
• INHIBITION OF IODINE UPTAKE
• Garlic
• HYPOGLYCEMIA
• Atractylodes, Scrofularia, Lycium, Burdock

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ORGAN SYSTEM TOXICITY

• CARDIOVASCULAR
• HYPOTENSION
• Astragalus, Codonopsis, Prunella, Scrofularia,
  Salvia
• HYPERTENSION
• Ginseng
• HYPERTENSION / CORONARY SPASM / PALPITATIONS
• Ephedra

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• ECHINACEA Echinacea purpurea and angustifolia

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ECHINACEA Echinacea purpurea, pallida, and
angustifolia

• USES
• Immune system stimulant (E. augustifolia)
• Anti-infective (E. pallida)
• Wound healing (E. purpurea)
• MECHANISM
• Alkylamide and polysaccharide consituents result
  in immunostimulation secondary to enhanced
  phagocytosis and non-specific T-cell stimulation
  in vitro and in vivo.
• STUDIES
• 1) Decrease in flu-like symptoms from 10 to 7
  days
• 2) 15 reduction in number of colds
• TOXICITY
• tachyphylaxix, ?hepatotoxicity, shivering, fever,
  weakness, potential cross allergy with daisy and
  sunflower families, autoimmune exacerbations

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GINKGO Gingko biloba

• GINGKO
• Gingko biloba

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GINKGO Gingko biloba

• USES
• Antioxidant, Enhances Cerebral Blood Flow,
  Reduces symptoms of peripheral vascular disease
  and Raynauds, Alleviates vertigo and tinnitus
• MECHANISM
• Ginkgolides antagonize PAF(gingkolide B)
• antioxidant activity of flavenoid, terpenoids,
  organic acids
• STUDIES
• 1) improvement in 2 of 3 clinical parameters of
  cognitive function at 12 weeks in 309 pateients
  in placebo controlled study
• 2) improvement in two tests of cognitive function
  in 2020 Alzheimers patients with no difference
  in adverse effects compared to placebo

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GINKGO Gingko biloba

• TOXICITY
• GI upset, headache
• spontaneous hyphema (case report)
• spontaneous bilateral subdural hematomas (case
  report)
• ?neurotoxicity (gingkotoxin in both leaf and
  seed)
• POTENTIAL DRUG INTERACTIONS
• NSAIDs, aspirin, anticoagulants
• ANESTHETIC CONSIDERATIONS
• Regional anesthesia, preoperative bleeding
  history, ?labs, intraoperative bleeding

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• St. Johns Wort

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ST. JOHNS WORT Hypericum perforatum

• USES
• Antidepressant for mild to moderate depression
• Possible anti-inflammatory and anti-viral
  activity
• MECHANISM
• 10 constituents which may contribute to
  pharmacoloical effects
• (naphthodianthroms, flavonoids, xanthose,
  bioflavonoids)
• weak MAOI or selective serotonin reuptake
  inhibition
• STUDIES
• Hypericum extracts superior to placebo and
  equivalent to amitriptyline or imipramine with
  less side effects in meta analysis of 1757
  patients

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ST. JOHNS WORT Hypericum perforatum

• TOXICITY
• photosensitivity (hypericin)
• MAOI (NIH sponsored study ongoing)
• possibly serotonism (headache, sweating,
  dizziness, agitation)
• DRUG INTERACTIONS
• beta-symphathomimetics, ephedra, meperidine,
  serotonin reuptake inhibitors, photosensitizing
  medications
• ANESTHETIC CONSIDERATIONS
• as above, ?discontinue prior to surgery
• may prolong effects of anesthesia

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GARLICAllium sativum
GARLICAllium sativum
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GARLICAllium sativum

• USES
• Antispasmodic, antiseptic, bacteriostatic,
  antiviral, promotor of leukocytosis, hypotensive,
  hypocholesterolemic
• MECHANISM
• not stated
• inhibition of epinephrine induced in vitro
  platelet aggregation
• STUDIES
• hypotensive effect in many animal studies
• modest decrease in serum cholesterol and
  triglycerides in human studies using large doses
  (300mg TID)

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GARLICAllium sativum

• TOXICITY
• inhibition of spermatogenesis in rats
• decreased platelet aggregation with one case
  report of spontaneous spinal epidural hematoma in
  an 87 yo man
• elevated INR
• DRUG INTERACTIONS
• antiplatelet agents
• warfarin potentiation
• ANESTHETIC CONSIDERATIONS
• as above

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GINSENG Asian Panax ginsengAmerican Panax
quinquefoliusSiberian Eleutherococcus senticosus
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GINSENG Asian Panax ginsengAmerican Panax
quinquefoliusSiberian Eleutherococcus senticosus

• USES
• Adaptogen, mood and energy level enhancer,
  antioxidant, hypoglycemic
• MECHANISM
• ?augmentation of adrenal steroidogenesis via
  pituitary
• immunomodulation via increased IgG and IgM
  responses to primary and secondary challenges
  associated with increased interferon production
• enhancement of cell mediated immunity and natural
  killer cell activity
• hypoglycemic via ginsenoside Rb2 and panaxans I,
  J, K, and L

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GINSENG Asian Panax ginsengAmerican Panax
quinquefoliusSiberian Eleutherococcus senticosus

• STUDIES
• animal studies of immune effects
• Double-blind, placebo controlled study of 36 type
  II diabetics revealed subjective improvement in
  mood, vigor, well-being, decreased weight and
  increased physical activity, and moderately lower
  fasting serum glucose
• TOXICITY
• Ginseng abuse syndrome (gt15g/day) - sleepiness,
  hypertonia, edema
• hypertension, insomnia, vomiting, headache,
  epistaxis
• Stevens-Johnson Syndrome (case report)
• Vaginal bleeding with oral and topical use (case
  reports)
• Mastalgia and diffuse breast nodularity (case
  report)
• ?fetal adrogenization (Siberian ginseng) (case
  report)

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GINSENG Asian Panax ginsengAmerican Panax
quinquefoliusSiberian Eleutherococcus senticosus

• DRUG INTERACTIONS
• Possible interaction with antiplatelet drugs and
  anticoagulants based on case report of decreased
  INR in patient on warfarin
• Possible potentiation of CNS stimulants or
  excacerbations of manic or psychotic symptoms in
  predisposed individuals
• ANESTHETIC CONSIDERATIONS
• as related to above

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GOLDENSEAL Hydrasis canadensis
Golden Seal
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GOLDEN SEAL Hydrasis canadensis

• USES
• Diuretic
• Anti-inflammatory
• Laxative
• Hemostatic
• TOXICITY / PRECAUTIONS
• Oxytotic (pregnancy)
• Overdose may cause paralysis
• Aquaretic (not diuretic)
• May worsen edema and/or hypertension

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SAW PALMETTO Serenoa repens
Saw Palmetto
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SAW PALMETTO Serenoa repens

• USES
• Benign prostatic hypertrophy
• Diuretic, urinary antiseptic, anabolic
• MECHANISM
• antiandrogenic acivity of hexane extract
• inhibits binding of dihydrotestosterone at
  receptors and 5-alpha-reductase activity
• STUDIES
• 2 double blind studies showed significant
  improvement in objective and subjective data
  versus placebo and finasteride

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SAW PALMETTO Serenoa repens

• TOXICITY
• GI upset
• DRUG INTERACTIONS
• caution with hormonal therapies

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VALERIAN Valeriana officinalis
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VALERIAN Valeriana officinalis

• USES
• Mild sedative
• Mild anxiolytic
• MECHANISM
• not stated
• STUDIES
• decreased sleep latency in 2 studies, one showing
  mild EEG changes suggesting hypnotic effect

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VALERIAN Valeriana officinalis

• ANESTHETIC CONSIDERATIONS
• Will likely potentiate barbiturate and
  benzodiazepine effects
• (Should not be used with alcohol)

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FEVERFEW Tanacetum parthenium
Feverfew
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FEVERFEW Tanacetum parthenium

• USES
• Migraine
• MECHANISM
• Suppresses prostaglandin production by 86-88 (no
  anti-cyclooxygenase activity)
• ?parthenolide
• STUDIES
• shown effective in reducing number of episodes in
  2 placebo-controlled, blinded studies of 17 and
  72 patients

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FEVERFEW Tanacetum parthenium

• TOXICITY
• GI irritation or aphthous ulcerations in 5-15
• Inhibits platelet activity
• Rebound headaches
• Post-feverfew syndrome - nervousness, tension,
  headache, insomnia, stiffness, joint pain,
  tiredness
• DRUG INTERACTIONS
• anti-platelet agents, anticoagulants
• ANESTHETIC CONSIDERATIONS
• bleeding history, ?labs, discontinue preop

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GINGERZingiger oficinale
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GINGERZingiger oficinale

• USES
• antinauseant
• antispasmodic
• MECHANISM
• not stated for primary use
• thromboxane synthetase inhibition
• STUDIES
• not found

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GINGERZingiger oficinale

• TOXICITY
• potent inhibitor of thromboxane synthetase -
  bleeding
• DRUG INTERACTIONS
• NSAIDS, aspirin, anticoagulants
• ANESTHETIC CONSIDERATIONS
• Bleeding history, ?preop labs, intraop bleeding
• Discontinue prior to surgery

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• EPHEDRA
• Ephedra sinica

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EPHEDRA (MA HUANG)Ephedra sinica

• USES
• Diet aid
• Bacteriostatic
• Antitussive
• MECHANISM
• release of endogenous catecholamines (indirect
  sympathomimetic)
• STUDIES
• Not found

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EPHEDRA (MA HUANG)Ephedra sinica

• TOXICITY
• hypertension (mild to severe), tachycardia,
  cardiomyopathy, dysrhythmia, MI, CVA, seizure,
  psychosis, death
• DRUG INTERACTIONS
• MAOIs, cardiac glycosides, halothane, oxytotics
• ANESTHETIC CONSIDERATIONS
• Discontinue prior to surgery
• As related to above

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World Wide Web Resources

• Organization Address Links
• FDA http//www.fda.gov MEDWATCH
• special nutritionals adverse event
  monitoring system
• American http//www.herbs.org Herb Research
• Botanical Foundation
• Council
• University of http//www.nnlm.nlm. MEDLINE,
  pictures
• Washington nih.gov
• Medicinal Herb
• Garden

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• Winslow and Kroll, Herbs as Medicines, Archives
  of Internal Medicine, 158, 2192-2199.
• Miller, L., Herbal Medicinals Selected Clinical
  Considerations Focusing on Known or Potential
  Drug-Herb Interactions, Archives of Internal
  Medicine, 158, 2200-2211.
• Murphy, Preoperative Considerations with Herbal
  Medicines, AORN Journal, 69(1), 173-183.
• Tsen, et al, Alternative Medicine Use in
  Presurgical Patients, Anesthesiology, 93,
  148-151.

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World Wide Web Resources

• American Botanical Council www.herbalgram.org
• NIH Office of Alternative Medicine altmed.od.nih.g
  ov
• U.S. Dept of HHS www.healthfinder.gov
• (search alternative medicine)
• U.S. Pharmacopeia www.usp.org