HERBAL MEDICINES ANESTHETIC IMPLICATIONS

صفحه 1:
oe 

صفحه 2:


صفحه 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 0 She is very motivated to avoid PONV this ‏ان‎ 

صفحه 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. 

صفحه 5:


صفحه 6:


صفحه 7:
HERBAL MEDICINE HISTORY 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 1960’s Establishment of Office of Alternative Medicine, National Institutes of Health 1992 1994 FDA Dietary Supplement and Health Education Act 

صفحه 8:
HERBAL MEDICINE EPIDEMIOLOGY ٠ 3 - 93% of U.S. population use herbals * Generally higher internationally 

صفحه 9:
Incidence of Herbal Medicine Use Among Age Groups 96 20 2030 31-40 41-50 51-60 61-70 71-80 >80 Age group eRe nC BT ane CEB a rae ۰ A eee ese 

صفحه 10:
SR ee Re eens Herb 507 ۱ ۷ ‎at ۱‏ 9 رووه ان لادم 

صفحه 11:
Top Ten Selling Herbs 1995 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. JOHN’S WORT, VALERIAN, FEVER FEW) 

صفحه 12:
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 

صفحه 13:
QUALITY CONTROL 1994 Dietary Supplement and Health Education Act Compromise act No requirements for: Proof of efficacy Proof of safety ‏1ماصمی بانلهتن ۲۵۲ علبمل مها‎ Cannot promise a specific cure, but may claim effect Burden of proving product unsafe lies with FDA 

صفحه 14:
QUALITY CONTROL * Variability between manufactures and batches * Potency affected by growing conditions, storage, handling, and preparation - up to 10,000 fold difference in potency 

صفحه 15:
QUALITY CONTROL * Inaccuracy of labels * Contamination with other substances - Mandrake(scopolamine) or Snakeroot (reserpine) in Ginseng preparations - Use of additives not found on label (NSAID’s, 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 

صفحه 16:
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 ا ل ااا ا ‎PKB ime‏ dietary supplements is poor (FDA web site available at: http://www.fda.gov Potential safety issues include: - Drug-herhb interactions 1۳ cttw g microsomal liver enzymes) ~ Toxicity from contaminants ~ Delayed intervention with allopathic treatment 

صفحه 17:
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 << Sree ‏ا ل‎ 

صفحه 18:
ORGAN SYSTEM TOXICITY (from Winslow and Kroll, 1998) CENTRAL NERVOUS SYSTEM 5-5 NERVOUSNESS / AGITATION/INSOMNIA / MOOD CHANGES DEPRESSION / CONFUSION / HALLUCINATIONS Cone Cee M tC Com or)) HALLUCINOGENIC ۳ ,۷۵۵4 «وعهنل رومصانط رتیه ههلا رهتاه‌طما رفقط ره دحه 0 ۱ CHOLINERGIC TOXICITY (CONTAINS ATROPINE, SCOPOLOMINE, HYOSCYAMINE) aOR 0 5 ل ‎Peony, Salvia, Tang-kuei‏ SEIZURES / PSYCHOSIS / COMA Sayre 

صفحه 19:
ORGAN SYSTEM TOXICITY (from Winslow and Kroll, 1998) PULMONARY PULMONARY HYPERTENSION Chinese herbal teas ALLERGIC / IMMUNOLOGIC CONTACT DERMATITIS Propolis, Garlic, Echinacea, Melaleuca oil (6۱ ۰ COR AO UB eee bE WHOL} ‏لكك‎ RENAL Dyes Pino ec ‏ل‎ HYPERTENSION / SODIUM AND WATER RETENTION / HYPOKALEMIA ۱ eel aces Tee hd 

صفحه 20:
ORGAN SYSTEM TOXICITY (from Winslow and Kroll, 1998) ENDOCRINOLOGIC GYNECOMASTIA / VAGINAL BLEEDING Content Crise tC teTETOT GOITERS / HYPERTHYROIDISM / HYPOTHYROIDISM 1۱ Cr TET ETT) INHIBITION OF IODINE UPTAKE Garlic HYPOGLYCEMIA Atractylodes, Scrofularia, Lycium, Burdock 

صفحه 21:
ORGAN SYSTEM TOXICITY CARDIOVASCULAR HYPOTENSION Astragalus, Codonopsis, Prunella, Scrofularia, Salvia HYPERTENSION ‏ومه‌عمنه‎ HYPERTENSION / CORONARY SPASM / PALPITATIONS Ephedra 

صفحه 22:


صفحه 23:
ECHINACEA Echinacea purpurea, pallida, and angustifolia USES SoM COMET ceo) ‏ا ا‎ ‏ا ان‎ ts rte) سنانا ص علسوعم متسعغتعصمء علتتقطءع هد تز[مم قصة عقتصه وتلق ‎immunostimulation secondary to enhanced phagocytosis and non-‏ .اانا صل قسة متغتد سد دمت تناك لاعع-] عمتعومه بدا ‎nce oe Una Cad‏ ۱ ‎T Emo meo cy‏ لك TOXICITY tachyphylaxix, ?hepatotoxicity, shivering, fever, weakness, potential cross allergy with daisy and sunflower families, autoimmune exacerbations 

صفحه 24:
GIN GIO 

صفحه 25:
GINKGO Gingko biloba USES Antioxidant, Enhances Cerebral Blood Flow, Reduces Secs ie reco ia crt be etatt tie Cenc Oe asntt att) (7۲ Ginkgolides antagonize PAF(gingkolide B) PRCT CUR Aa e CACC Cs SOCOM oe TC tC STUDIES EOC a Ra Roe tert eee cre vst function at 12 weeks in 309 pateients in placebo controlled study 1 ‏ا‎ ‎1 ‎compared to placebo 

صفحه 26:
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 NSAID’s, aspirin, anticoagulants ANESTHETIC CONSIDERATIONS ‎C ME ay re tAA MCT CK a aeed‏ كاذنا ‎labs, intraoperative bleeding‏ 

صفحه 27:
000000 os ately ‏ا ا‎ PHOTO-Mimi Kamp 

صفحه 28:
ST. JOHN’S WORT Hypericum perforatum دنت ‎Antidepressant for mild to moderate depression‏ ‎Possible anti-inflammatory and anti-viral activity‏ MECHANISM 10 constituents which may contribute to pharmacoloical effects Cy CLE NCSC ERC CM SCONCE) weak MAOI or selective serotonin reuptake inhibition Ey ue) eC eee see Octet UR Ciclo at ANA CRom ine mnnC RB Ceeist Chie e nt ey analysis of 1757 patients 

صفحه 29:
ST. JOHN’S WORT Hypericum perforatum TOXICITY PUES Ine Ny tes tot}) 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 DONS COCR cesar oy 

صفحه 30:
GARLIC Allium sativum 9. 1.01 

صفحه 31:
GARLIC تاه تال USES Antispasmodic, antiseptic, bacteriostatic, antiviral, promotor [0 tats meters ents MECHANISM not stated inhibition of epinephrine induced in vitro platelet aggregation STUDIES ۱ ie CeCe NAT Meat Crd modest decrease in serum cholesterol and triglycerides in human studies using large doses (300mg TID) 

صفحه 32:
GARLIC تاه تال TOXICITY inhibition of spermatogenesis in rats decreased platelet aggregation with one case report of spontaneous spinal epidural hematoma in an 87 yo man torte Bitsy DRUG INTERACTIONS antiplatelet agents warfarin potentiation ANESTHETIC CONSIDERATIONS as above 

صفحه 33:
GINSENG Asian Panax ginseng American Panax ‏ید تست‎ ۳ Eleutheroco 

صفحه 34:
GINSENG Asian Panax ginseng American Panax quinquefolius Siberian Eleutherococcus senticosus USES 1 Cte Oe Nts Cte Petree MECHANISM Pte CRs e ‏ا‎ ‎immunomodulation via increased IgG and IgM responses to ‏و[‎ ‎increased interferon production SNCs ces esc Ctcc ert iage et Rutty B tity cell activity CR CCS CE ‏ا‎ A 

صفحه 35:
GINSENG Asian Panax ginseng American Panax quinquefolius Siberian Eleutherococcus senticosus STUDIES ل ا لتك 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 994 Ginseng abuse syndrome (>15g/day) - sleepiness, hypertonia, ney ۱ C MCh Mm tC Cte TMS ciety 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) 

صفحه 36:
GINSENG Asian Panax ginseng American Panax quinquefolius Siberian 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 

صفحه 37:
oe Hydrastis canadensis : 601۵90 500۱ ۱ ۲ ۹ 

صفحه 38:
GOLDEN SEAL Hydrasis canadensis USES ‏از‎ ‎۱ ‏اا ل‎ Laxative Hemostatic TOXICITY / PRECAUTIONS Oxytotic (pregnancy) Overdose may cause paralysis Aquaretic (not diuretic) May worsen edema and/or hypertension 

صفحه 39:
| ‏ات‎ ‎Enea ies <i TUE pee gens 

صفحه 40:
SAW PALMETTO ا USES Benign prostatic hypertrophy ۱ tram ntl CMTE TTC! MECHANISM antiandrogenic acivity of hexane extract ۱ Bee alpha-reductase activity ناو ‎double blind studies showed significant improvement in‏ 2 ‎objective and subjective data versus placebo and‏ ‎finasteride‏ 

صفحه 41:


صفحه 42:
۱ بوفلقسله 681 - 

صفحه 43:
الل ۱/۵ Valeriana officinalis USES ‏ات۱۵۱۱‎ ‎Mild anxiolytic MECHANISM ‏0مهاء ام‎ STUDIES decreased sleep latency in 2 studies, one showing mild EEG changes suggesting hypnotic effect 

صفحه 44:
الل ۱/۵ Valeriana officinalis ANESTHETIC CONSIDERATIONS Will likely potentiate barbiturate and benzodiazepine effects (Should not be used with alcohol) 

صفحه 45:
0 ‎ee ae 23 ۳‏ كا ‎ ‏2 م وه ‎Photo: Mimi-Kamp ~‏ ‎ 

صفحه 46:
FEVERFEW 1 USES Migraine MECHANISM Suppresses prostaglandin production by 86-88% (no anti-cyclooxygenase activity) ۷۵۰۱۰۱۱ ‏ارت‎ STUDIES shown effective in reducing number of episodes in 2 placebo-controlled, blinded studies of 17 and 72 patients 

صفحه 47:
FEVERFEW 1 ۱۱94 GI irritation or aphthous ulcerations in 5-15% ‏جاتطتاعة أعاعغه1ام وغتطتطم1‎ 1 ‏دعطعهلهعط لسستمطع‎ ا ا ا ا نا ‎headache, insomnia, stiffness, joint pain, tiredness‏ DRUG INTERACTIONS PVG UCIC imeem TRCN ANESTHETIC CONSIDERATIONS bleeding history, ?labs, discontinue preop 

صفحه 48:
Roscoe Zingiber officinale 

صفحه 49:
GINGER Zingiger oficinale USES ‏ل لقان‎ antispasmodic MECHANISM not stated for primary use thromboxane synthetase inhibition ۱۱۱ 20۲ 00 

صفحه 50:
GINGER Zingiger oficinale TOXICITY potent inhibitor of thromboxane synthetase - bleeding DRUG INTERACTIONS 2154125, ‏كأسة1ناندمعتاقة ستستوكة‎ ANESTHETIC CONSIDERATIONS Bleeding history, ?preop labs, intraop bleeding Discontinue prior to surgery 

صفحه 51:


صفحه 52:
EPHEDRA (MA HUANG) Ephedra sinica USES Cae Bacteriostatic USUAL MECHANISM release of endogenous catecholamines (indirect sympathomimetic) STUDIES Not found 

صفحه 53:
EPHEDRA (MA HUANG) Ephedra sinica TOXICITY hypertension (mild to severe), tachycardia, cardiomyopathy, dysrhythmia, MI, CVA, seizure, psychosis, death DRUG INTERACTIONS MAOI’s, cardiac glycosides, halothane, oxytotics ANESTHETIC CONSIDERATIONS Discontinue prior to surgery PBC ‏ا‎ 

صفحه 54:
World Wide Web Resources Organization Address ۱۳۹۹ FDA _http://www.fda.gov MEDWATCH ore Masta Acree MC ante treat temen ceil American http://www.herbs.org Herb Research Botanical Foundation ۵ University of http://www.nnlm.nlm. MEDLINE, pictures Washington nih.gov Medicinal Herb Garden 

صفحه 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. 

صفحه 56:
World Wide Web Resources American Botanical Council © www.herbalgram.org NIH Office of Alternative Medicine altmed.od.nih.gov U.S. Dept of HHS www.healthfinder.gov (search “alternative medicine”) U.S. Pharmacopeia www.usp.org