Dr SParthasarathy MD DA DNB PhD FICAIDRA Diploma in Software based statistics Why this subject Surveys estimate that 22 to 32 of patients undergoing surgery use herbal ID: 1011807
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1. Herbal drugs and anesthesia Dr S.Parthasarathy MD., DA., DNB., PhD., FICA.,IDRA., Diploma in Software based statistics
2. Why this subject ? Surveys estimate that 22% to 32% of patients undergoing surgery use herbal medications70 % of them dont reveal 90 % anesthesiologists don’t ask
3. What are they ? Derived from plants Systems which promote ! Ayurveda, Yoga, Unani, Siddha, Homeopathy and Naturopathy.Non allopathy in simple terms Millions use in India Even 12 % use in USA !
4. Why they use ? We think they are safer They lack side effects Deficient allopathy Some chronic illness like diabetes , hypertension and even AIDS – no cure Wheezing ? Jaundice ?
5. Why a few prefer ? Over the counter availability Thought of as dietary supplements ! Are there rigorous testing ? Do they contain ? Are there any standards ? Post intake analyses ?
6. Common herbal medicinesEchinacea ( காட்டு கொழுஞ்சன்)Anti bacterial and anti viral includes anti fungal Some immune boosting action Anti inflammatory action GI disturbances, giddiness, hepatotoxic – halothane ? in patients with pre-existing hepatic dysfunction as well as in surgeries where hepatic functions and hepatic blood flow is more likely to be compromised.Renal transplant – can interfere
7. Ephedra vulgaris – சொமாமும்ephedrine, pseudoephedrine, methylephedrine promoting weight loss, increasing energy and for treating most of the respiratory infectionsCatecholamine action – sympathetic stimulationsensitize the myocardium, to develop arrhythmogenic potential on administration of exogenous catecholamines. Catecholamine depletion on long use MAO inhibitors – reactions - Stop before one day atleast
8. Garlic - Allium sativum –பூண்டுallicin Natural antibiotic Anti platelet ? Breast milk promotion bad breath, bad odor from skin, gastrointestinal upsets, and skin rashesAntiplatelet – should we need 7 days stopping prior ?
9. Ginger – இன்ஜிale and galanolactone Motion sickness Nausea and vomiting Sore throat Interfers with antihypertensives But anti platelet effects – 7 days prior ! Risk of neuraxial bleedsAdditive hypoglycemic effects
10. Gingko biloba- (அடல்) terpenoids and flavonoidsApproved in Germany for use in dementia-- peripheral vascular disease, vertigo, age-related muscular degeneration –Possible bleeding Stop 36 hours prior
11. Ginseng - Panax ginsengsteroidal saponineHypoglycemic effects Beware of intraop hypoglycemiaMood elevation antiplatelet Mild sympathomimetic effect May be stopped 7 days prior !
12. Herbal diureticsHerbal diuretics include dandelion, green tea, golden seal (Hydrastis canadensis), saw palmetto berries, and spearmintAffects rennin angiotensin mechanism significant electrolyte disturbances
13. Kava – kava drinks – kava lactones is used as an anxiolytic and sedative with effects mediated by potentiation of gamma-aminobutyric acid (GABA) transmission. It potentiates the effects of barbiturates and benzodiazepines.Think of dosageSide-effects include hepatotoxicity, dermatological changes andextrapyramidal-like syndrome 36 hour stoppage !
14. Vallarai Brain tonic Many dishes Health tonic May be risking contact dermatitis and liver damage with long term use
15. St. John's wort – Hypericum perforatumவெட்ட பாக்குhypericin and hyperforin, which act by inhibiting the re-uptake of serotonin, norepinephrine, and dopamine by the neurons.Drugs utilizing this enzyme substrate, P4503A4, include alfentanil, midazolam, lignocaine, calcium channel blockers, and serotonin receptor antagonist, and as such, their clinical effects are reducedStop before five days atleast
16. Valerian – tagarai valerian GABA reuptake inhibitor Sedation and anxiolysisAdverse effects reported include tremor, headache, hepatic dysfunction, and cardiac disturbances..Stopping can cause withdrawal symptoms Beware before surgery
17. Thorn apple, another alleged constituent of mafesian, can be used to treat cough, asthma, and arthralgia.Tetradoxin effect Cardiac rhythm disturbances
18. Turmeric – மஞ்சள் The beneficial effects of turmeric are believed to be due to its anti-infective, analgesic, anti-inflammatory, and anti-oxidant actionsThe ability to inhibit microsomal enzyme P450 causes the prolonged duration of many drugs like fentanyl, midazolam, warfarin, theophylline, bupivacaine, ropivacaine, and lignocaine. Duration of stoppage ! Not mentioned
19. thoothuvalai Solasadin – saponins Respiratory infections Antiinflammatory antidiabetic Beware of rhythm disturbances
20. Thulasi Anxiety Stress Respiratory infections Wheezing . Bronchitis might slow blood clotting, so there is a concern that it could increase the risk of bleeding during and after surgery. Stop using holy basil at least 2 weeks before a scheduled surgery.
21. Guava leaves Increase sperm count Anti diabetic Colicky pain etc Side effect profile ? ASA guidelines not known
22. Black pepper This, in turn breaks down protein in the stomach, improving the process of digestion. Black pepper is known to have a great amount of antioxidant properties. It also has benefits against bacterial growth, particularly in the intestinal tract.. Theophylline , ketoconozole rifampicin Propronolol interact
23. Liquorice (Glycyrrhiza glabra)Glycyrrhizin Glycyrrhetinic acidOral – ulcers, chronic gastritis, arthritis, inflammation and bronchitisIncreased cortisol effect Potassium depletionWater retention BP drugs !
24. Aloe vera Laxative Topical use Antiplatelet effects Increased risk of bleeding
25. Feverfew (Tanacetum parthenium)Used for migraine Parthenolide – a sesquiterpene lactoneRisk of bleeding
26. Primrose oil Menopausal syndromes Rheumatoid Diabetes Risk of intraoperative seizure !
27. Keezhanelli Phyllanthus niruri is a popular folk remedy with powerful medicinal properties. Some research supports its use for kidney stones, gallstones, liver health, and diabetes. Still, much of the research is inconclusive. Possible stomach upset – otherwise OK
28. PAC !! An altered coagulation profile can potentially be caused by garlic, ginseng, and ginkgo, and can result in more than the anticipated blood loss during a surgical procedure. The effect of general anesthesia can be potentiated by kava and valerian, which are known to possess sedative properties.The hepatic microsomal enzyme cytochrome P450 3A4 is stimulated by St. John's wort and has been observed to alter the metabolism of an immunosuppressant and oncological chemotherapy
29. Possible ! Steroid synthesis Antiplatelet and neuraxial bleed risk Sympathetic system variation Immune boosting Hypoglycemia Electrolyte imbalance Unknown complication – take herbal history
30. Summary A history of taking herbal medicine must be obtained in all patients. If in doubt, a herbal medicine should be stopped for 2 weeks before proceeding to anaesthesia and surgery.Postponing is difficult – then identify the herb and see the ASA guidelines to stop !