Herbal medicines and perioperative care

Context Widespread use of herbal medications among the presurgical populati on may have a negative impact on perioperative patient care. Objectives To review the literature on commonly used herbal medications in the context of the perioperative period and provide rational strategies for managing their preoperative use. Data Sources The MEDLINE and Cochrane Collaboration databases were searched for articles published between January 1966 and December 2000 using the se arch terms herbal medicine, phytotherapy, and alternative medicine and the names of the 16 most commonly used herbal medications. Additional data sour ces were obtained from manual searches of recent journal articles and textb ooks. Study Selection We selected studies, case reports, and reviews addressing t he safety and pharmacology of 8 commonly used herbal medications for which safety information pertinent to the perioperative period was available. Data Extraction We extracted safety, pharmacodynamic, and pharmacokinetic i nformation from the selected literature and reached consensus about any dis crepancies. Data Synthesis Echinacea, ephedra, garlic, ginkgo, ginseng, kava, St John's wort, and valerian are commonly used herbal medications that may pose a co ncern during the perioperative period. Complications can arise from these h erbs' direct and pharmacodynamic or pharmacokinetic effects. Direct effects include bleeding from garlic, ginkgo, and ginseng; cardiovascular instabil ity from ephedra; and hypoglycemia from ginseng, Pharmacodynamic herb-drug interactions include potentiation of the sedative effect of anesthetics by kava and valerian, Pharmacokinetic herb-drug interactions include increased metabolism of many drugs used in the perioperative period by St John's wor t. Conclusions During the preoperative evaluation, physicians should explicitl y elicit and document a history of herbal medication use. Physicians should be familiar with the potential perioperative effects of the commonly used herbal medications to prevent, recognize, and treat potentially serious pro blems associated with their use and discontinuation.