Perioperative anesthesia clinical considerations of alternative medicines

Herb-drug interactions: A short review on central and peripheral nervous system drugs

Herbal medicines are widely perceived as natural and safe remedies. However, their concomitant use with prescribed drugs is a common practice, often undertaken without full awareness of the potential risks and frequently without medical supervision. This practice introduces a tangible risk of herb-drug interactions, which can manifest as a spectrum of consequences, ranging from acute, self-limited reactions to unpredictable and potentially lethal scenarios. This review offers a comprehensive overview of herb-drug interactions, with a specific focus on medications targeting the Central and Peripheral Nervous Systems. Our work draws upon a broad range of evidence, encompassing preclinical data, animal studies, and clinical case reports. We delve into the intricate pharmacodynamics and pharmacokinetics underpinning each interaction, elucidating the mechanisms through which these interactions occur. One pressing issue that emerges from this analysis is the need for updated guidelines and sustained pharmacovigilance efforts. The topic of herb-drug interactions often escapes the attention of both consumers and healthcare professionals. To ensure patient safety and informed decision-making, it is imperative that we address this knowledge gap and establish a framework for continued monitoring and education. In conclusion, the use of herbal remedies alongside conventional medications is a practice replete with potential hazards. This review not only underscores the real and significant risks associated with herb-drug interactions but also underscores the necessity for greater awareness, research, and vigilant oversight in this often-overlooked domain of healthcare.

Complications and treatment errors in root coverage procedures

Root coverage procedures have become very common in clinical dental practice. Even though these techniques are considered safe, the clinician may face several issues during the therapy due to their surgical nature. Some of these issues can be defined strictly as complications inherent to the procedure, whereas others are medical errors or treatment errors. This review will focus on describing treatment errors and complications that may arise during different phases of the root coverage therapeutic process and on how to prevent and manage them.

Perioperative Medication Management in Elective Plastic Surgery Procedures

BACKGROUND

Perioperative medication management is vital to maintain patient safety while under anesthesia, as well as to avoid postoperative complications. Plastic surgeons make daily decisions on whether to ask a patient to stop taking medication before their surgery. These important decisions can affect bleeding risk, wound healing, and interactions with anesthetics, which can range from minor to life-threatening. Current plastic surgery literature lacks a comprehensive review of perioperative medication management, with existing reports focusing on specific procedures and specific medication classes.

METHODS

A PubMed database search was conducted for articles through July 2021. The bibliographies of included studies were also examined for articles not acquired in the initial search queries. The authors included studies on medication usage and perioperative guidance in patients undergoing elective plastic surgery procedures. The authors excluded studies unrelated to plastic surgery and studies where the medications were used as an intervention. Abstracts, animal studies, studies involving the pediatric population, and book chapters were also excluded, as well as articles not published in English.

RESULTS

A total of 801 papers were identified by our search terms. After title and abstract screening, 35 papers were selected for full-text review. After full-text review, 20 papers were selected for inclusion, with an additional 6 papers from cited references added. Of the 26 papers, 6 papers discussed psychotropic drugs, 6 papers discussed medications affecting hemostasis, 4 papers discussed hormone-containing medications, 3 papers discussed antilipid medications, 2 papers discussed antihypertensive medications, 2 papers discussed herbal supplements, 1 paper discussed both psychotropic and herbal supplements, 1 paper discussed medications affecting wound healing, and 1 paper discussed rheumatologic medications. A summary of those recommendations was then compiled together.

CONCLUSIONS

The perioperative medication management in elective plastic surgery procedures remains a complex and multidisciplinary process. It is important to manage these patients in a case-by-case manner and to consult a specialist when necessary. Careful medication reconciliation is essential to decrease the likelihood of adverse outcomes and interactions with perioperative anesthetics.

COVID-19 Crisis, Herbal Medicines, and Natural Products - Concerns and Suggestions

: Since the outbreak of the COVID-19 pandemic in the last days of 2019 in China, medical experts and organizations worldwide have proposed guidelines for its prevention and treatment. However, despite the availability of state-of-the-art technologies, modern medicine specialists have so far not been successful in controlling it. This has led traditional medicine experts to propagate their knowledge to prevent and cure COVID-19, creating an open debate. According to scientific literature, traditional medicine experts claim beneficial effects of herbal medicines against viral infections and their effectiveness in controlling the symptoms of respiratory disorders. Modern medicine specialists express their concerns about the quality, safety, and efficacy of herbal medicines, in addition to the risk of herb-drug interactions and the lack of randomized clinical studies. Herbal medicines have been popular since prehistoric times, and during the COVID-19 pandemic, they are increasingly used worldwide. The lack of definite cure and the high cost of available modern medicines have also promoted the use of herbal medicines. An evidence-based approach using herbal medicines with proven antiviral activities or containing compounds providing symptomatic relief in COVID-19 can be considered for clinical studies. The interaction of herbal medicines with modern drugs should also be considered in patients taking them. Traditional and modern medicine aim to provide effective and safe treatment and prevent COVID-19 infection. Considering the ground realities of the COVID-19 crisis and keeping in view the worldwide use of herbal medicines, in our opinion, the pros and cons of their use should be carefully weighed, and practical solutions should be considered.

Exploration of Predictive Modeling of Defense Health Agency & Department of Veterans Affairs Beneficiaries Dietary Supplements Use

PURPOSE

The purpose of this study was to predict dietary supplements (DS) use among Defense Health Agency (DHA) and Veterans Affairs (VA) beneficiaries who were scheduled for surgical procedures.

DESIGN

This was a predictive descriptive multicenter study with a convenience sample of 2,623 adult subjects. After institutional review board exemption, data collection occurred preoperatively via electronic survey. Participation was voluntary and data unidentifiable.

METHODS

Data were collected in preoperative anesthesia clinics during preanesthetic evaluations, or in surgery holding areas immediately prior to surgery, using a validated data collection tool. The total convenience sample size was 2,623 subjects from 6 medical centers. Data were voluntarily, anonymously, and verbally obtained from subjects using electronic survey methodology. Collected data included: gender, age, rank, beneficiary status, race, body mass index, tobacco use, marital status, and knowledge of DS side effects and drug interactions. For predictive modeling of DS use, multiple logistic regression was performed for binary outcomes via SPSS.

FINDINGS

For binary logistic regression the predictors were significant for the following outcomes: taking DS (education, sex, age, and race; P < .05), knowledge of side effects (age, race, and rank; P < .05), and believe they are having side effects (age; P < .05).

CONCLUSIONS

Understanding DS use is central to predict and anticipate potential negative sequelae in patient outcomes in anesthesia. College education, females, Caucasians, and increasing age are indicators for greater DS use. These results provide opportunities for perianesthesia nurses to improve preoperative assessments, design patient specific perianesthesia care, and enhance patient education. Further research is recommended.

Evaluation of Herbal Product Use and Preanaesthetic Questioning of Couples Undergoing In Vitro Fertilisation

Objective

This study aimed to determine the levels of herbal product use among couples in vitro fertilisation (IVF) treatment in Turkey and the status of questioning in terms of herbal product usage.

Methods

After ethics committee approval, the study included 257 people, which were the couples receiving treatment in Dokuz Eylül University IVF units from 1^st August, 2018, to 28^th February, 2019. The couples were given 16-questions survey form to determine their herbal product use. Vitamin and herbal product use in the past 3 months was separately questioned.

Results

Significant differences were identified between women and men only in terms of age group. The rate of answering yes to the question about herbal product use in the study group was 13.6%, whereas 40.8% participants marked at least 1 item on the list of herbal products. Most people stated that they used herbal products by increasing the amounts in daily consumption. The top 5 products included onion, garlic, thyme, cinnamon and carob. Of the female patients being treated with IVF, 62.5% used vitamin supplements and 48.6% used herbal products. Of the men undergoing the same treatment (partners of the female participants), 37.5% used vitamin supplements and 51.4% used herbal products.

Conclusion

Asking questions to patients receiving infertility treatment or anaesthesia is important in terms of medication interactions and treatment success. For a laborious and costly treatment, such as IVF, detailed history should be taken and herbal product used and cessation times must be searched in detail.

Complementary medicines use amongst elective surgery patients at a public tertiary hospital: A prospective observational cohort study in Australia

BACKGROUND

and purpose. Complementary medicines (CM) use may result in untoward effects perioperatively. The study purpose is to identify CM pattern of use amongst elective surgery patients, and improve effectiveness of information collection relating to CM use.

MATERIALS AND METHODS

This is a prospective observational cohort study. CM questionnaire was administered alongside standard hospital forms at pre-admission clinic over eight weeks.

RESULTS

992 patients attended pre-admission clinic; 317 patients were included in analysis. Introduction of CM questionnaire increased disclosure rate by 11.7% giving a total prevalence of 44.2%. CM use was significantly higher in females and in older patients. Top CM reported were vitamin D (12%) and omega-3 (12%). Majority of patients did not plan to withhold CM before surgery, and were not concerned about perioperative risks.

CONCLUSION

Pre-admission clinics need to encourage CM disclosure. Patient education of potential risks and greater engagement of clinicians in patient assessment is required.

Optimizing Patient Outcomes and Safety With Liposuction

Since its advent in the early 1980s, liposuction has made tremendous advancements, making it the most popular aesthetic surgery performed today. The goal of this Continuing Medical Education (CME) article is to provide a foundation of knowledge of the relevant anatomy, preoperative evaluation, intraoperative technique, and postoperative management for surgeons performing liposuction. Finally, the prevention and management of potential complications will be reviewed along with measures to optimize patient safety and outcomes.

Integrative care of the patient with head and neck cancer

Objective

To review the literature on integrative care of the patient with head and neck cancer.

Methods

A review of the English language literature for articles relating to integrative care of patients with head and neck cancer, focusing on treatment of sequelae of surgery and chemoradiation.

Results

Many studies show a significant utilization of nontraditional (complementary/integrative) treatments by patients in dealing with head and neck cancer. Treatment of head and neck cancer entails potentially debilitating consequences of surgery and/or chemoradiation on cosmesis, speech, swallowing, breathing, and quality of life. While complementary/integrative treatments for head and neck cancer are not established as effective therapies, their use for relieving sequelae of treatment, improving quality of life, and providing potential chemoprevention is well documented.

Conclusion

Given the landscape of increasing use of nontraditional methodologies by patients with head and neck cancer and the complexity of care, the head and neck cancer surgeon should be aware of the uses and abuses of complementary/integrative medicine by patients as they navigate their care.

Level of Evidence

5

Perioperative Herbal Supplement Use in Cancer Patients: Potential Implications and Recommendations for Presurgical Screening

BACKGROUND

Products made from botanicals that are used to maintain or improve health are known as herbal supplements, botanicals, or phytomedicines. Many herbs have a long history of use and claimed health benefits. However, many herbal supplements and botanicals have potent pharmacologic activity that can contribute to adverse effects and drug interactions. The use of herbal supplements by cancer patients in the perioperative period is common and consistent with the substantial increase in the use of alternative medical therapies.

METHODS

We reviewed the literature to examine the constituents, safety, pharmacokinetics, and pharmacodynamics of those herbal supplements that are predominantly used by cancer patients.

RESULTS

Different supplements possess antiplatelet activity, adversely interact with corticosteroids and central nervous system depressant drugs, have gastrointestinal manifestations, produce hepatotoxicity and nephrotoxicity, and produce additive effects when used with opioid analgesics.

CONCLUSIONS

With the increasing use of herbal supplements by cancer patients, surgical staff need to screen patients pre-surgically for use of these supplements. Clinical practice guidelines are needed for screening and prevention of herbal supplement usage to prevent potential adverse events that may arise from herbal medications taken alone or combined with conventional therapies during the perioperative period.

Mind the gap: Disclosure of dietary supplement use to hospital and family physicians

OBJECTIVE

We aim to compare patients' perspectives on communication with their hospital physicians (HPs) and primary care physicians (PCPs) on patients' dietary and herbal supplements (DHS) use.

METHODS

We conducted a cross-sectional prospective study among in-patients using structured questionnaires on DHS use. Multivariate logistic regression models assessed variables influencing doctor-related reasons for patients' nondisclosure of supplement use.

RESULTS

Of 452 DHS users identified, 133 (29.4%) used herbs and 319 (70.6%) used non-herbal supplements. DHS users reported that PCPs were more aware of DHS consumption than HPs (70.1% vs. 34.1%, P<0.0001). PCPs initiative to detect supplement use was higher compared with HPs (P<0.0001). Doctor-related reasons for non-disclosure of DHS use were more prominent in a hospital setting. Multivariate logistic regression model suggested association between older patient age and doctor-related non-disclosure (p=0.03). DHS use was recorded in only 33 patients medical files.

CONCLUSIONS

Doctor-patient communication concerning DHS use is significantly poorer during hospitalization compared with primary-care settings. A significant barrier for in-hospital disclosure is doctor-related.

PRACTICE IMPLICATIONS

Continuity of care between community and hospital physicians regarding patients' DHS use should be improved due to the safety implications of such use. Educating physicians on DHS and improving communication could bridge this gap.

Commonly Used Dietary Supplements on Coagulation Function during Surgery

BACKGROUND

Patients who undergo surgery appear to use dietary supplements significantly more frequently than the general population. Because they contain pharmacologically active compounds, dietary supplements may affect coagulation and platelet function during the perioperative period through direct effects, pharmacodynamic interactions, and pharmacokinetic interactions. However, in this regard, limited studies have been conducted that address the pharmacological interactions of dietary supplements. To avoid possible bleeding risks during surgery, information of potential complications of dietary supplements during perioperative management is important for physicians.

METHODS

Through a systematic database search of all available years, articles were identified in this review if they included dietary supplements and coagulation/platelet function, while special attention was paid to studies published after 1990.

RESULTS

Safety concerns are reported in commercially available dietary supplements. Effects of the most commonly used natural products on blood coagulation and platelet function are systematically reviewed, including 11 herbal medicines (echinacea, ephedra, garlic, ginger, ginkgo, ginseng, green tea, kava, saw palmetto, St John's wort, and valerian) and 4 other dietary supplements (coenzyme Q₁₀, glucosamine and chondroitin sulfate, fish oil, and vitamins). Bleeding risks of garlic, ginkgo, ginseng, green tea, saw palmetto, St John's wort, and fish oil are reported. Cardiovascular instability was observed with ephedra, ginseng, and kava. Pharmacodynamic and pharmacokinetic interactions between dietary supplements and drugs used in the perioperative period are discussed.

CONCLUSIONS

To prevent potential problems associated with the use of dietary supplements, physicians should be familiar with the perioperative effects of commonly used dietary supplements. Since the effects of dietary supplements on coagulation and platelet function are difficult to predict, it is prudent to advise their discontinuation before surgery.

Alternative medicine and anesthesia: Implications and considerations in daily practice

Nowadays, herbal medicines are widely used by most of the people, including the pre-surgical population. These medicines may pose numerous challenges during perioperative care. The objective of the current literature review is to dwell upon the impact of the use of herbal medicines during the perioperative period, and to review the strategies for managing their perioperative use. The data was generated from various articles of different journals, text books, web source, including, Entrez Pubmed, Medscape, WebMD, and so on. Selected only those herbal medicines for which information on, safety, usage, and precautions during the perioperative period was available. Thereafter, the information about safety, pharmacokinetics, and pharmacodynamics from selected literature was gathered and analyzed. The whole review focused on the fact that these commonly used alternative medicines could sometimes pose as a concern during the perioperative period, in various ways. These complications could be due to their direct action, pharmacodynamic effect, or pharmacokinetic effect. In view of the serious impacts of herbal medicine usage in perioperative care, the anesthesiologist should take a detailed history, especially stressing on the use of herbal medicine during the preoperative anesthetic assessment. The anesthesiologist should also be aware of the potential perioperative effects of those drugs. Accordingly, steps should to be taken to prevent, recognize, and treat the complications that may arise due to their use or discontinuation.

What is integrative oncology and can it help my patients?

Integrative oncology lends itself to the comprehensive practice of gynecologic oncology with multiple tools and interventions that can impact on QoL and survival. However, there remains a paucity of well-designed, well-powered randomized control trials on various CAM modalities for gynecologic cancer patients. The reasons for the lack of level 1 evidence include the nascent state of integrative medicine as a science, the limitations on CAM funding, the relative lack of integration of CAM practitioners into the oncology community, and absence of strict regulation of herbs and supplements by the US FDA. The use of CAM as adjunctive therapies will likely continue given the patient-driven trends to date, and given the evidence for at least safety and potentially efficacy, our patients deserve our willingness to use all possible approaches to improving their outcomes. Continued evolution of our ability to specifically measure and describe QoL will further our ability to hone in on domains most important to patients and their survival and allow practitioners to make patient-specific recommendations. Multimodal programs that include physical activity, stress management, and diet have the potential to address demonstrated deficits in PWB and FWB in ovarian cancer patients which suggests a model of collaborative gynecologic oncology care). Integrative oncology represents a holistic approach to patient care whose goal is maximization of patient quantity and quality of life. Patients can achieve this optimal outcome through the synergy of conventional care, integrative modalities, lifestyle modifications, and supportive care. Refer to Table 4 for a listing of integrated medicine Internet resources.

Bleeding risks of herbal, homeopathic, and dietary supplements: a hidden nightmare for plastic surgeons?

The utilization of complementary and alternative medicine has increased tremendously in the last two decades. Herbal products, homeopathic medicines, and dietary supplements are extremely popular and are available without a prescription (which likely contributes to their popularity). Despite their "natural" characteristics, these remedies have the potential to cause bleeding in patients who undergo surgery. The high use of these supplements among cosmetic surgery patients, coupled with increasing reports of hematomas associated with herbal and homeopathic medicines, prompted the authors to conduct a comprehensive review focused on bleeding risks of such products in an effort to raise awareness among plastic surgeons. This review focuses on 19 herbs, three herbal formulas, two herbal teas, and several other supplements that can cause bleeding perioperatively and postoperatively. In addition to being aware of such adverse effects, plastic surgeons must adequately screen all patients and educate them on the possible dangers associated with these treatments.

Perioperative and intraoperative maneuvers to optimize surgical outcomes in skull base surgery

There are many approaches to obtaining a workable endoscopic surgical field in sinus surgery. With extended sinus and transdural endoscopic surgery, a more rigid approach must be taken. There are 3 main factors that invariably lead to poor surgical outcomes in endoscopic sinus and skull base surgery: bleeding, inadequate access, and unidentified anatomic anomalies. Bleeding is arguably the most common reason for incomplete resection. An understanding of microvascular and macrovascular bleeding allows a more structured approach to improve the surgical field in extended endoscopic surgery. The endoscopic surgeon should always be comfortable in performing the same procedure as an open operation. However, converting or abandoning an endoscopic procedure should rarely occur because much of this decision making should take place preoperatively. Along with poor hemostasis, inadequate access is an important cause of poor outcome. Evaluation of the anatomy involved by pathology but also the anatomy that must be removed to allow adequate exposure is important. This article reviews the current techniques used to ensure optimal surgical conditions and outcomes.

Patterns of usage of complementary and alternative medicine in general surgical patients

BACKGROUND

Use of complementary and alternative medicine (CAM) is becoming increasingly common. The purpose of this study was to determine the prevalence among general surgical patients, whether its use is related to disease type, and if postoperative patient-perceived problems and actual complications may be related to some CAM use.

METHODS

One hundred fifty-one consecutive patients over a 3 month period were queried. Demographic information was obtained from the medical record pertaining to age, gender, race, marital status, treatment and postoperative complications. CAM practices were divided into three categories: body/structure, herbal medications/supplements, and mind/spirit. Data were analyzed for overall use of CAM and type of CAM. Relationships of CAM use to gender, age, race, and disease type, patient-perceived postoperative problems, and actual incidence of postoperative complications were determined.

RESULTS

Sixty patients (40%) used some type of CAM: 17% body/structure interventions, 31% herbal medications, and 3% mind/spirit practices. Demographics of CAM use: 47% of Caucasians, compared to 29% of African-Americans (OR=2.2, p=0.03); 44% of females, compared to 34% of males (p=NS); 49% of patients</=60 years old, compared to 32% of patients>60 years old (OR=2.0, p=0.04); 48% of patients with a cancer diagnosis, compared to 31% of patients with a benign diagnosis (OR=3.1, p=0.04). Thirty-three of CAM patients reported some type of postoperative problem, compared to 26% of non-CAM patients (p=NS). Actual complication rates were 8% for CAM patients, compared to 11% for non-CAM patients (p=NS).

CONCLUSIONS

Use of CAM is relatively common, with younger, Caucasian patients with malignancies being the most common users. However, there seems to be no difference in perceived postoperative problems, nor actual postoperative complications between CAM and non-CAM users.

Herbal remedies: effects on clinical laboratory tests

CONTEXT

Complementary and alternative medicine (herbal medicines) can affect laboratory test results by several mechanisms.

OBJECTIVE

In this review, published reports on effects of herbal remedies on abnormal laboratory test results are summarized and commented on.

DATA SOURCES

All published reports between 1980 and 2005 with the key words herbal remedies or alternative medicine and clinical laboratory test, clinical chemistry test, or drug-herb interaction were searched through Medline. The authors' own publications were also included. Important results were then synthesized.

DATA SYNTHESIS

Falsely elevated or falsely lowered digoxin levels may be encountered in a patient taking digoxin and the Chinese medicine Chan Su or Dan Shen, owing to direct interference of a component of Chinese medicine with the antibody used in an immunoassay. St John's wort, a popular herbal antidepressant, increases clearance of many drugs, and abnormally low cyclosporine, digoxin, theophylline, or protease inhibitor concentrations may be observed in a patient taking any of these drugs in combination with St John's wort. Abnormal laboratory results may also be encountered owing to altered pathophysiology. Kava-kava, chaparral, and germander cause liver toxicity, and elevated alanine aminotransferase, aspartate aminotransferase, and bilirubin concentrations may be observed in a healthy individual taking such herbal products. An herbal product may be contaminated with a Western drug, and an unexpected drug level (such as phenytoin in a patient who never took phenytoin but took a Chinese herb) may confuse the laboratory staff and the clinician.

CONCLUSIONS

Use of alternative medicines may significantly alter laboratory results, and communication among pathologists, clinical laboratory scientists, and physicians providing care to the patient is important in interpreting these results.

Top-10 list of herbal and supplemental medicines used by cosmetic patients: what the plastic surgeon needs to know

BACKGROUND

Widespread use of herbal medications/supplements among the presurgical population may have a negative effect on perioperative patient care. Thus, the authors' goal was to identify the prevalence of such use in a cosmetic surgery patient population compared with use among the general public; to assess physician awareness of proper management of these herbal medications/supplements; and to review the literature to provide rational strategies for managing perioperative patients taking these remedies.

METHODS

To assess patient (n = 100) and general public (n = 100) usage rates, open-ended lists of (1) the most common herbal medications/supplements and (2) homeopathic treatments were compiled. Board-certified plastic surgeons (n = 20) were then given the same list of herbs/supplements and surveyed on their awareness of these treatments and perioperative side effects.

RESULTS

The usage rate for cosmetic versus public surveys for herbal medicines/supplements was 55 percent versus 24 percent (p < 0.001), with 35 percent versus 8 percent (p < 0.001) engaging in homeopathic practices, respectively. Cosmetic patients' top four herbal/supplements of usage were chondroitin (18 percent), ephedra (18 percent), echinacea (14 percent), and glucosamine (10 percent). The top four used by the general public were echinacea (8 percent), garlic (6 percent), ginseng (4 percent), and ginger (4 percent). The physician survey demonstrated awareness of 54 percent of the listed supplements/herbal medicines, 85 percent of which were not suggested to be discontinued preoperatively, with only ephedra achieving 100 percent physician discontinuation preoperatively.

CONCLUSIONS

Herbal medicines and supplements displayed greater prevalence in the cosmetic surgery population than in the population at large. Furthermore, side effects and potential complications warrant addressing these remedies as pharmaceuticals rather than as safe and "natural." Thus, a descriptive "top-10" list with perioperative recommendations was compiled for the plastic surgeon.