HERBAL MEDICINES ANESTHETIC IMPLICATIONS
اسلاید 1: www.tabaye.ir
اسلاید 2: HERBAL MEDICINES ANESTHETIC IMPLICATIONSM. Ron EslingerCRNA, MA, APNwww.aamsn.com
اسلاید 3: A 35 year old athletic woman with a history of migraines presents for ACL reconstruction. Her only pertinent history is previous PONV after 3 GA’s 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.
اسلاید 4: 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.
اسلاید 5: A 35 year old athletic woman with a history of migraines presents for ACL reconstruction. History of PONV.FeverfewGinger
اسلاید 6: 35 year old for posterior spinal fusion.St. John’s Wort
اسلاید 7: HERBAL MEDICINE HISTORYEarly archaeological evidence - Neanderthal16th Century Medicinal PlantsScientific method and the marginalization of Herbal Medicine - 19th CenturyRebirth of herbal medicine and natural health in the 1960’sEstablishment of Office of Alternative Medicine, National Institutes of Health 1992 1994 FDA Dietary Supplement and Health Education Act
اسلاید 8: HERBAL MEDICINE EPIDEMIOLOGY3 - 93% of U.S. population use herbalsGenerally higher internationally
اسلاید 9: Tsen, et al, Alternative medicine Use in Presurgical Patients, Anesthesiology, 93, 148-51Incidence of Herbal Medicine Use Among Age Groups% Age group
اسلاید 10: Tsen, et al, Alternative medicine Use in Presurgical Patients, Anesthesiology, 93, 148-51n=3106
اسلاید 11: Top Ten Selling Herbs 1995 Survey of 163 Health Food Retail Stores (Winslow and Kroll, 1998)ECHINACEAGARLICGOLDENSEALGINSENGGINKGOSAW PALMETTOALOEMA HUANGSIBERIAN GINSENGCRANBERRY(ST. JOHN’S WORT, VALERIAN, FEVER FEW)
اسلاید 12: ECONOMICS AND REIMBURSEMENT$553 million in 8000 health food stores - 1994$ 1.2 billion from all sources20% annual growth ratelargest growth area in retail pharmaciesincreasing coverage of herbals and alternative therapies by insurance and managed care industries
اسلاید 13: QUALITY CONTROL1994 Dietary Supplement and Health Education ActCompromise actNo requirements for:Proof of efficacyProof of safetyStandards for quality controlCannot promise a specific cure, but may claim effectBurden of proving product unsafe lies with FDA
اسلاید 14: QUALITY CONTROLVariability between manufactures and batchesPotency affected by growing conditions, storage, handling, and preparation - up to 10,000 fold difference in potency
اسلاید 15: QUALITY CONTROLInaccuracy of labelsContamination with other substancesMandrake(scopolamine) or Snakeroot (reserpine) in Ginseng preparationsUse of additives not found on label (NSAID’s, steroids, antibiotics, sedatives, hypnotics)Belladonna poisoning in herbal tea (NYC)Digitalis intoxication from mislabeled plant extractHeavy metals (lead, arsenic, cadmium, copper, mercury) in preparations from some foreign countries
اسلاید 16: EFFICACY AND SAFETYNo profit in conducting controlled studies in U.S.Reported effects stem from anecdotal reports and a few well controlled clinical trialsSystem for reporting ADR’s for herbals and dietary supplements is poor (FDA web site available at:http://www.fda.govPotential safety issues include:Drug-herb interactionsHerb-body interactions (inhibition or stimulation of microsomal liver enzymes)Toxicity from contaminantsDelayed intervention with allopathic treatment
اسلاید 17: ORGAN SYSTEM TOXICITY (from Winslow and Kroll, 1998)GASTROINTESTINALHEPATOTOXIC (MILD TO SEVERE)Chinese herbal teas, Mistletoe, Germander, Chaparral, ComfreyNAUSEA/VOMITTINGDandelion, Garlic, Ginseng, ChaparralDIARRHEAHerbal teas, Aloe, Ligustrum, Dandelion, Prunelia, Garlic, GinsengHEMATOLOGICANTICOAGULANT/ANTIPLATELETYarrow, Red clover, Tang-kuei, Pau d’arco, Salvia
اسلاید 18: ORGAN SYSTEM TOXICITY (from Winslow and Kroll, 1998)CENTRAL NERVOUS SYSTEMNERVOUSNESS / AGITATION/INSOMNIA / MOOD CHANGESDEPRESSION / CONFUSION / HALLUCINATIONSGinseng (long-term and higher doses)HALLUCINOGENICCatnip, Hops, Kava kava, Khat, Lobelia, Mandrake, Nutmeg, Jimson weed, Valerian, YohimbeCHOLINERGIC TOXICITY(CONTAINS ATROPINE, SCOPOLOMINE, HYOSCYAMINE)Jimson weedSEDATIONPeony, Salvia, Tang-kueiSEIZURES / PSYCHOSIS / COMAEphedra
اسلاید 19: ORGAN SYSTEM TOXICITY (from Winslow and Kroll, 1998)PULMONARYPULMONARY HYPERTENSIONChinese herbal teasALLERGIC / IMMUNOLOGICCONTACT DERMATITISPropolis, Garlic, Echinacea, Melaleuca oilSYSTEMIC LUPUS ERYTHEMATOSISAlfalfaRENALDIURESISBurdock, Astragalus, Peony, DandelionHYPERTENSION / SODIUM AND WATER RETENTION / HYPOKALEMIALicorice, Glycyrrhiza glabra, Glycyrrhiza radix
اسلاید 20: ORGAN SYSTEM TOXICITY (from Winslow and Kroll, 1998)ENDOCRINOLOGICGYNECOMASTIA / VAGINAL BLEEDINGGinseng (estrogen-containing)GOITERS / HYPERTHYROIDISM / HYPOTHYROIDISMKelp (iodine-containing)INHIBITION OF IODINE UPTAKEGarlicHYPOGLYCEMIAAtractylodes, Scrofularia, Lycium, Burdock
اسلاید 21: ORGAN SYSTEM TOXICITYCARDIOVASCULARHYPOTENSIONAstragalus, Codonopsis, Prunella, Scrofularia, SalviaHYPERTENSIONGinsengHYPERTENSION / CORONARY SPASM / PALPITATIONSEphedra
اسلاید 22: ECHINACEA Echinacea purpurea and angustifolia
اسلاید 23: ECHINACEA Echinacea purpurea, pallida, and angustifolia USESImmune system stimulant (E. augustifolia)Anti-infective (E. pallida)Wound healing (E. purpurea)MECHANISMAlkylamide and polysaccharide consituents result in immunostimulation secondary to enhanced phagocytosis and non-specific T-cell stimulation in vitro and in vivo.STUDIES1) Decrease in flu-like symptoms from 10 to 7 days2) 15% reduction in number of coldsTOXICITYtachyphylaxix, ?hepatotoxicity, shivering, fever, weakness, potential cross allergy with daisy and sunflower families, autoimmune exacerbations
اسلاید 24: GINKGO Gingko bilobaGINGKOGingko biloba
اسلاید 25: GINKGO Gingko bilobaUSESAntioxidant, Enhances Cerebral Blood Flow, Reduces symptoms of peripheral vascular disease and Raynaud’s, Alleviates vertigo and tinnitusMECHANISMGinkgolides antagonize PAF(gingkolide B) antioxidant activity of flavenoid, terpenoids, organic acidsSTUDIES1) improvement in 2 of 3 clinical parameters of cognitive function at 12 weeks in 309 pateients in placebo controlled study2) improvement in two tests of cognitive function in 2020 Alzheimer’s patients with no difference in adverse effects compared to placebo
اسلاید 26: GINKGO Gingko bilobaTOXICITYGI upset, headachespontaneous hyphema (case report)spontaneous bilateral subdural hematomas (case report)?neurotoxicity (gingkotoxin in both leaf and seed)POTENTIAL DRUG INTERACTIONSNSAID’s, aspirin, anticoagulantsANESTHETIC CONSIDERATIONSRegional anesthesia, preoperative bleeding history, ?labs, intraoperative bleeding
اسلاید 27: St. John’s Wort
اسلاید 28: ST. JOHN’S WORT Hypericum perforatumUSESAntidepressant for mild to moderate depressionPossible anti-inflammatory and anti-viral activityMECHANISM10 constituents which may contribute to pharmacoloical effects (naphthodianthroms, flavonoids, xanthose, bioflavonoids)weak MAOI or selective serotonin reuptake inhibitionSTUDIESHypericum extracts superior to placebo and equivalent to amitriptyline or imipramine with less side effects in meta analysis of 1757 patients
اسلاید 29: ST. JOHN’S WORT Hypericum perforatumTOXICITYphotosensitivity (hypericin)MAOI (NIH sponsored study ongoing)possibly serotonism (headache, sweating, dizziness, agitation)DRUG INTERACTIONSbeta-symphathomimetics, ephedra, meperidine, serotonin reuptake inhibitors, photosensitizing medicationsANESTHETIC CONSIDERATIONSas above, ?discontinue prior to surgerymay prolong effects of anesthesia
اسلاید 30: GARLIC Allium sativumGARLIC Allium sativum
اسلاید 31: GARLIC Allium sativumUSESAntispasmodic, antiseptic, bacteriostatic, antiviral, promotor of leukocytosis, hypotensive, hypocholesterolemicMECHANISMnot statedinhibition of epinephrine induced in vitro platelet aggregationSTUDIEShypotensive effect in many animal studiesmodest decrease in serum cholesterol and triglycerides in human studies using large doses (300mg TID)
اسلاید 32: GARLIC Allium sativumTOXICITYinhibition of spermatogenesis in ratsdecreased platelet aggregation with one case report of spontaneous spinal epidural hematoma in an 87 yo manelevated INRDRUG INTERACTIONSantiplatelet agentswarfarin potentiationANESTHETIC CONSIDERATIONSas above
اسلاید 33: GINSENG Asian Panax ginseng American Panax quinquefolius Siberian Eleutherococcus senticosus
اسلاید 34: GINSENG Asian Panax ginseng American Panax quinquefolius Siberian Eleutherococcus senticosusUSESAdaptogen, mood and energy level enhancer, antioxidant, hypoglycemicMECHANISM?augmentation of adrenal steroidogenesis via pituitaryimmunomodulation via increased IgG and IgM responses to primary and secondary challenges associated with increased interferon productionenhancement of cell mediated immunity and natural killer cell activityhypoglycemic via ginsenoside Rb2 and panaxans I, J, K, and L
اسلاید 35: GINSENG Asian Panax ginseng American Panax quinquefolius Siberian Eleutherococcus senticosusSTUDIESanimal studies of immune effectsDouble-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 glucoseTOXICITYGinseng abuse syndrome (>15g/day) - sleepiness, hypertonia, edemahypertension, insomnia, vomiting, headache, epistaxisStevens-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)
اسلاید 36: GINSENG Asian Panax ginseng American Panax quinquefolius Siberian Eleutherococcus senticosusDRUG INTERACTIONSPossible interaction with antiplatelet drugs and anticoagulants based on case report of decreased INR in patient on warfarinPossible potentiation of CNS stimulants or excacerbations of manic or psychotic symptoms in predisposed individualsANESTHETIC CONSIDERATIONSas related to above
اسلاید 37: GOLDENSEAL Hydrasis canadensisGolden Seal
اسلاید 38: GOLDEN SEAL Hydrasis canadensisUSESDiuretic Anti-inflammatory Laxative HemostaticTOXICITY / PRECAUTIONSOxytotic (pregnancy)Overdose may cause paralysisAquaretic (not diuretic)May worsen edema and/or hypertension
اسلاید 39: SAW PALMETTO Serenoa repensSaw Palmetto
اسلاید 40: SAW PALMETTO Serenoa repensUSESBenign prostatic hypertrophyDiuretic, urinary antiseptic, anabolicMECHANISMantiandrogenic acivity of hexane extractinhibits binding of dihydrotestosterone at receptors and 5-alpha-reductase activitySTUDIES2 double blind studies showed significant improvement in objective and subjective data versus placebo and finasteride
اسلاید 41: SAW PALMETTO Serenoa repensTOXICITYGI upsetDRUG INTERACTIONScaution with hormonal therapies
اسلاید 42: VALERIAN Valeriana officinalis
اسلاید 43: VALERIAN Valeriana officinalisUSESMild sedativeMild anxiolyticMECHANISMnot statedSTUDIESdecreased sleep latency in 2 studies, one showing mild EEG changes suggesting hypnotic effect
اسلاید 44: VALERIAN Valeriana officinalisANESTHETIC CONSIDERATIONSWill likely potentiate barbiturate and benzodiazepine effects(Should not be used with alcohol)
اسلاید 45: FEVERFEW Tanacetum partheniumFeverfew
اسلاید 46: FEVERFEW Tanacetum partheniumUSESMigraine MECHANISMSuppresses prostaglandin production by 86-88% (no anti-cyclooxygenase activity)?parthenolideSTUDIESshown effective in reducing number of episodes in 2 placebo-controlled, blinded studies of 17 and 72 patients
اسلاید 47: FEVERFEW Tanacetum partheniumTOXICITYGI irritation or aphthous ulcerations in 5-15%Inhibits platelet activityRebound headachesPost-feverfew syndrome - nervousness, tension, headache, insomnia, stiffness, joint pain, tirednessDRUG INTERACTIONSanti-platelet agents, anticoagulantsANESTHETIC CONSIDERATIONSbleeding history, ?labs, discontinue preop
اسلاید 48: GINGER Zingiger oficinale
اسلاید 49: GINGER Zingiger oficinaleUSESantinauseantantispasmodicMECHANISMnot stated for primary usethromboxane synthetase inhibitionSTUDIESnot found
اسلاید 50: GINGER Zingiger oficinaleTOXICITYpotent inhibitor of thromboxane synthetase - bleedingDRUG INTERACTIONSNSAID’S, aspirin, anticoagulantsANESTHETIC CONSIDERATIONSBleeding history, ?preop labs, intraop bleedingDiscontinue prior to surgery
اسلاید 51: EPHEDRAEphedra sinica
اسلاید 52: EPHEDRA (MA HUANG) Ephedra sinicaUSESDiet aidBacteriostaticAntitussiveMECHANISMrelease of endogenous catecholamines (indirect sympathomimetic)STUDIESNot found
اسلاید 53: EPHEDRA (MA HUANG) Ephedra sinicaTOXICITYhypertension (mild to severe), tachycardia, cardiomyopathy, dysrhythmia, MI, CVA, seizure, psychosis, deathDRUG INTERACTIONSMAOI’s, cardiac glycosides, halothane, oxytoticsANESTHETIC CONSIDERATIONSDiscontinue prior to surgery As related to above
اسلاید 54: World Wide Web ResourcesOrganizationAddressLinksFDAhttp://www.fda.govMEDWATCHspecial nutritionals adverse event monitoring systemAmerican http://www.herbs.orgHerb Research BotanicalFoundationCouncilUniversity ofhttp://www.nnlm.nlm.MEDLINE, picturesWashingtonnih.govMedicinal HerbGarden
اسلاید 55: 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.
اسلاید 56: World Wide Web ResourcesAmerican Botanical Councilwww.herbalgram.orgNIH Office of Alternative Medicinealtmed.od.nih.govU.S. Dept of HHSwww.healthfinder.gov(search “alternative medicine”)U.S. Pharmacopeiawww.usp.org
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