Preparing for surgery can be a daunting task for patients, particularly when it comes to sorting through what can be a laundry list of home medications. Further complicating this picture is the ever-increasing prevalence of herbal products and the propensity of nondisclosure by patients using these products. These remedies have been around for centuries, and their use in Western societies is increasing for a number of reasons, with a contributing factor possibly being the belief that they are "safer."
However, it should be noted that these supplements are not always so benign. Herbals are not held to the same testing standards as most other prescription medications by the Food and Drug Administration due to them being classified as dietary supplements. As such, they tend to have wide variability in content and quality.
When considering herbals in the context of upcoming anesthesia and surgery, an easy mnemonic is the Three G's: Garlic, Ginkgo, and Ginseng, as each of these can have effects of anticoagulation and thus increase the risk for perioperative bleeding.
Garlic, although better known as a tasty additive for cooking, has also been used to potentially prevent atherosclerosis by reducing cholesterol levels, blood pressure, and thrombus formation. The problems come from its effects on organosulfur compounds, many of which can irreversibly inhibit platelet aggregation and increase the risk of bleeding during and after surgery. Considering the lifespan of platelets is 8-9 days, it is recommended that garlic be stopped at least 7 days prior to surgery. Doing so allows for the regeneration of normal platelets to a sufficient level for surgery.
Ginkgo is used for a number of reasons including peripheral vascular disease, altitude sickness, and cognitive disorders, among others. The compounds thought to be responsible notably include flavonoids and terpenoids, which unfortunately also contribute as a potent inhibitor of platelet activation and should be avoided in combination with aspirin, warfarin, and nonsteroidal anti-inflammatory drugs. On the basis of pharmacokinetic data, ginkgo should be stopped at least 36 hr before surgery.
Finally, ginseng has widespread use worldwide for, among other reasons, supposed mood enhancement, increased immune function, and athletic ability. The effects are attributed to ginsenosides, which actually act as steroid hormones. In vitro, ginsenosides inhibit platelet aggregation while also prolonging the prothrombin time and partial thromboplastin time. Continuing the theme of the previous two herbals, this obviously puts the patient at risk for increased bleeding. In addition to the bleeding issue, ginseng lowers blood glucose levels. This can be of particular concern for surgical patients, as hypoglycemia can occur due to the perioperative fasting periods. Thus, ginseng should be discontinued at least 24 hr prior to surgery and perhaps even 7 days before surgery due to the potential platelet inhibition.
These three herbals account for only a small fraction of the supplements patients take; however, they demonstrate the impact that these home medical remedies can have on surgical outcomes. Knowing the implications of these herbal remedies can help patients better understand why they should be stopped before surgery, ideally increasing compliance and, in turn, improving patient outcomes. Educating patients is an integral role of any health care professional, and in doing so it empowers patients to take control of their own health. Educating patients about the effects their herbal supplements could have on their surgery will contribute to compliance and an optimal surgical outcome.
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