October FY20

[sarahrollison]

The October Journal Club article is presented by Angie Brooks. She chose an article that discusses frequently used herbal medications and supplements and their physiologic effects. Use of herbal medications has increase drastically over the past 20 years - this information can be especially vital information for our anesthetic case management. Enjoy!

Please see the article attached to this month's Journal Club email.

Questions for discussion:

1.Why is it important for anesthesia providers to be vigilant when interviewing patients preoperatively?
2.What herbal supplements pose a concern for impaired coagulation? Which herbs may potentiate other anesthetic medications that we currently use?

[LarSharVeA Bailey]

There are various complimentary and alternative medicines that have reactions with drugs that patients are currently taking and those we administer in the perioperative period. For some time, I have known St. John's wort as the great inducer along with the anti-epileptics and cigarette smoking. What I have learned after reading the article is that St. John's wort interaction with SSRIs and MAOIs can cause serontin syndrome. This is particularly concerning considering that serontonin syndrome occurs infrequently and is thus misdiagnosed for malignant hyperthermia, post operative, delirium, or drug withdrawal.

In short, all of the CAMs that start with a G can impair coagulation. Kava and Valerian can potentiate drugs we use via their enhancement of gamma amino butyric acid.

[Ben Waldbaum]

1.Oftentimes patients don't consider herbals to be medications and are completely surprised to hear that there may be implications from them during their surgery. I find it best to explicitly ask them if they take any herbal medications.

2.There are a few mentioned in the article, but personally I don't like to rely on memorizing them as supplements are constantly changing as they are for the most part unregulated. So when a patient is on an herbal, i'll look it up to learn about any relevant interactions

[jkim54]

1. It is important during the preop interview process to specifically ask our patients what supplements and herbal medications they take, especially since many patients do not consider them to be significant enough to mention. Given the number of potential side effects and adverse interactions with our anesthetic drugs, it would serve us well to pointedly ask our patients what - if any - CAMs they take.

2. The herbal supplements that can impair coagulation are: garlic, ginger, chamomile (potentiates Warfarin), kava. Supplements that may potentiate other anesthetic medications are: Kava, Valerian.

[Anne McNulty]

My perspective on things may be different due to many years of practice and reading the same articles over and over. This article did not tell me anything that I have not heard before. I have never taken care of a pt that had a known untoward reaction to any herbal med. Many people are totally unaware that a herbal med can have a negative effect on their body. The lack of regulation opens the door for people to buy the cheapest herbal remedy . The cheaper the herb, the more likely it may be contaminated. I can think of many incidences of regulated drugs being contaminated not to mention our water supply. Case reports without scientific evidence are not valuable. this article did not mention CBE oil , which is now for sale in every gas station and supermarket.

e

[kel]

A preop that is 100 % complete and accurate is always an amazing thing and sometimes not as easy to achieve as one may think . The more we know before the anesthetic the better. A complete preop allows us to provide a custom anesthetic and troubleshoot better.

Impair Coagulation: In school I too learned about the CAMs that start with G
Garlic
Ginger
Chamomile
Potentiate
Kava
Valerian

[Kristen Praesel Lang]

1.Why is it important for anesthesia providers to be vigilant when interviewing patients preoperatively? Patients may not consider herbal supplements as medications and may omit herbal medication use from their pre-op med list. Some herbal medications can impair coagulation and increase a patient's risk of bleeding during surgery. It is therefore important to obtain this information in a pre operative evaluation.


2.What herbal supplements pose a concern for impaired coagulation? Which herbs may potentiate other anesthetic medications that we currently use? Herbal supplements that impair coagulation include ginger, garlic, ginseng, ginko, and chamomile. Kava and Valerian can potentiate other anesthetic medications.


​

[Jocelyn Datud]

1.Most of the time, patients would rarely mention herbal medications that they are taking unless you specifically mention it to them. Hence, we should be specific when asking them questions about medications.
2.Garlic, ginger, chamomile, and kava are some of the herbal medications that can affect coagulation. Garlic, kava, and ginger affect platelet function. Chamomile, potentiates warfarin. Valerian and St. John's Wort can affect certain medications. Valerian potentiates benzodiazepines. St. John's Wort decreases efficacy of warfarin, digoxin, anticonvulsants, and antiretroviral drugs.

[Jennifer Hannon]

1. Some patients do not consider herbal supplements as medications and may not even report herbal medication use. Melatonin is even advertised as a non-medicinal product. There are herbal medications can impair coagulation and increase sedation during surgery. A pre operative interview can unmask omitted supplements.

2. Herbal supplements that impair coagulation are the G's. Kava, Melatonin, CBD oil, and Valerian can potentiate other anesthetic medications.


​

[aileenm4]

herbal medication/supplement use in pediatric patients is minimal to none. So, I do not find the need to ask about these on my daily preop evaluation. And I dont find the need to memorize all herbal medication interactions.
with that being said, it seems important to inquire from the adult population of patients. even though the clinical interactions maybe rare ( bleeding, hypotension etc.) knowing that your patient is taking herbal supplements may help you prepare or know what your dealing with.
there is no way you will get patients to stop taking these 1-2 weeks prior to surgery.  The surgeons would have to be responsible for this information because not all patients go to the anesthesia preop clinic 1-2 weeks before.

[Dahlia Rouchon]

1. It's important to inquire about supplemental medicines and vitamins as patients frequently don't believe them to be a part of their true
medication list. If no one asks, the information may not be offered. It can then be a cause of unanticipated additional bleeding in the OR.
2. Medications that can alter coagulation are ginkgo, ginger and garlic. Agents that can affect anesthetics include Kava and Valerian. Anesthetic techniques may need to be altered as a result.

[Katya]

1. Since herbal supplements can have adverse affects on adult patient population including extra bleeding, additional sedation, and others, we need to be vigilant about what they take and how often. We should question them not just about supplements but herbal teas as I myself love herbal teas with ginger and chamomile.
2. Herbals that start with G's: ginger, ginseng, garlic can interfere with coagulation process and Kava, melatonin, valerian root can increase sedation and potentiate anesthetics.

[Jessica Hadley]

1. To echo everyone else, yes a thorough preoperative history is very important including asking a patient regarding any herbal supplements that are being taken. I also agree that it would be impossible to memorize all the potential interactions given the sheer number of supplements available on the market. I am stunned by the multiple aisles of supplements available at some stores and the purported health claims they are making.

2. As mentioned, Ginger, ginseng, ginko, and garlic can interfere with coagulation. Kava and Valerian can potentiate anesthetics.

[Wai-Ling Lo]

1.Why is it important for anesthesia providers to be vigilant when interviewing patients preoperatively?

Thorough preoperative interview is important so that we can individualize the anesthesia plan accordingly to provide safe/sound anesthesia care and avoid complications.



2.What herbal supplements pose a concern for impaired coagulation? Which herbs may potentiate other anesthetic medications that we currently use?

​The article mentioned some common herbal meds but there are a lot more out there that people (especially ethnic groups) are taking in various forms (e.g. tea, spices, and local application). For example, turmeric supplement is really common nowadays and it potentiates the effect of anticoagulants. Patients can be drinking turmeric tea, using it as spices or taking it in pill form. The bottom line is, like the other had said, we have to ask them specifically what herbal medicine/tea that they are taking and look them up as new evidence may be available everyday.

[emedina1]

Why is it important for anesthesia providers to be vigilant when interviewing patients preoperativelyI agree with my co-league that these herbal supplement can pose some complications
into-operatively. I.e. excessive bleeding.
I don't believe that we should really go in dept in the study of these supplements suffice to say that we should be aware of potential effects and then plan our anesthetics accordingly.