HDS and Surgery

Good morning! You are going to the floor with your coffee in hand to start a new day. You go to the floor and find that Mr. Gomez has not gone to surgery yet.

The Pre-Op nurse pages you

Concern: The pre-op nurse says that Mr. Gomez cannot undergo the procedure because he uses herbs.

Is this nurse correct?

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Answer: Although it is common for children and adults to use dietary supplement prior to surgery, little is known about the benefits or risks to surgical patients using dietary supplements (Lee, 2006; Glintborg, 2005; Everett, 2005; Noonan, 2004; Crowe, 2004; Lin, 2004). There are no national guidelines for the use or disuse of HDS prior to surgery. The American Society of Anesthesiologists makes no formal statement or official policy on the preoperative use of dietary supplements (Anonymous, 2003). For elective surgery many sources recommend stopping surgery two weeks prior to the procedure. This is not base on any clinical studies.

The Surgery Resident pages you

Concern: After hearing you fill her in about Mr. Gomez, the surgery resident does not want to take Mr. Gomez to the operation room because he has been on fish oil and is therefore at risk of bleeding.

Is this residents correct?

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Answer: No, she is not correct. Please review the information below.

In this case, you check Mr. Gomez's PT, PTT and they were normal; therefore, there is no problem in proceeding with the surgery. If lab values were abnormal, it would obviously be a problem. It is true that fish oil may decrease platelet aggregation and prolong bleeding time.Omega-3 fatty acids may increase the risk of bleeding, although there is little evidence of significant bleeding risk at low doses.

the Anesthesia Resident pages you

Concern: the anesthesia resident is worried that he is taking St. Johns wort and it will interact with the anesthesia.

Is this residents correct?

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Answer: Yes, this is a concern. Please review the information below.

Currently the data on anesthesia and St. John's wort is based on the case reports. Overall, it has been found (human case reports) that the use of St. John's wort before anesthesia may cause complications, including cardiovascular collapse and delayed emergence. St. John's wort induces CYP3A4 and interacts with p-glycoprotein, making it possible that it might increase the metabolism of medications metabolized through this pathway. Well-documented SJW interactions include: reduced blood cyclosporin concentration, as suggested by multiple case reports as well as by clinical trials, and reduced plasma drug concentration of antiretroviral (e.g., indinavir, nevirapine) and anticancer (i.e., irinotecan, imatinib) drugs.

OPTIONAL: Click here for information about St. John's Wort interactions

Click the link below for a review paper on St. John's Wort’s Interactions

Herb-drug interactions with St John's wort (Hypericum perforatum): an update on clinical observations

Interactions with St. John’s wort

Drug	Strength of documentation	Outcome of interaction
Warfarin	Suspected based on changes in INR in case reports and in a study in 12 healthy volunteers	Decrease in INR
Digoxin	Suspected based on controlled studies	No clinical outcomes; decreased digoxin plasma levels
Verapamil	Suspected based on a study in 8 healthy volunteers	No clinical outcomes; but a signficant decrease in bioavailability (50%)
HMGCoA reductase inhibitors	Suspected in clinical study	No clinical signs; decreased plasma blood levels of simvastatin
Benzodiazepines	Suspected based on pharmacokinetic studies	No clinical signs; decreased serum levels (25% - 50%) of several benzodiazepines
Tricyclic antidepressants	Possible based on study of 12 depressed patients	No documented clinical effects; decreased plasma levels noted
Protease inhibitors	Suspected based on a single day study in healthy volunteers	Significant (49% - 99%) reduction in serum levels of indinavir

For more information about St. John's wort, click here.

Click for References

Gurley BJ, Gardner SF, Hubbard MA, Williams DK, Gentry WB, Cui Y, et al. Cytochrome P450 phenotypic ratios for predicting herb-drug interactions in humans. Clin Pharmacol Ther. 2002 Sep;72(3):276-87.
Hennessy M, Kelleher D, Spiers JP, Barry M, Kavanagh P, Back D, et al. St Johns wort increases expression of P-glycoprotein: implications for drug interactions. Br J Clin Pharmacol. 2002 Jan;53(1):75-82.
Borrelli F, Izzo AA. Herb-drug interactions with St John's wort (Hypericum perforatum): an update on clinical observations. Aaps J. 2009 Dec;11(4):710-27.

the Infectious Disease Fellow pages you

Concern: The infectious disease fellow is worried Mr. Gomez's acidophilus will give him an infection.

Is this fellow correct?

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Answer: No, she is not correct. In fact, probiotics are helpful for anti-biotic associated diarrhea. Please review the information below.

Prevention of Antibiotic-Associated Diarrhea (AAD)

There are a large number of clinical trials and several meta-analyses evaluating the effects of probiotics in preventing antibiotic-associated diarrhea. Some IV antibiotics selectively eradicate lactobacilli and bifidobacteria leaving other bacteria to flourish and subsequently to diarrheal episodes in some patients. Probiotics recolonize the gut and rebalance the intestinal flora.

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