When examining what patients are using that may affect their surgical course, the greatest concern and awareness needs to be in the domain of biologically based therapies. A survey of 2,560 surgical patients in five California hospitals revealed that 68% of patients were using botanicals, 44% of them did not consult their physician, 56% did not inform their anesthesiologists, and 47% did not stop them before their surgery. Variables that were associated with use included female gender, age 35 to 49 years, higher income, Caucasian race, higher education, and problems with sleep, joints, back, allergies, and addiction (110). A survey based in a tertiary care center examined the use of botanicals and vitamins in patients preoperatively (N = 3,106). Of the patients studied, 22% were using botanicals and 51% were using vitamins. The typical users were women in the age range of 40 to 60 years. The most commonly used compounds were echinacea, ginkgo biloba, St. John’s wort, garlic, and ginseng (111). In another study based in a university medical center that surveyed patients undergoing outpatient surgery, 64% of patients were using supplements: 90% of them were using vitamins, 43% were using garlic extracts, 32% ginkgo biloba, 30% St. John’s wort, 18% ma huang, 12% echinacea, and others were using aloe, cascara, and licorice (112).
Effects on Surgery Many of the most commonly used substances have effects of which surgeons and anesthesiologists should be aware. Botanicals used with anesthesia can lead to the following complications:  Prolongation of anesthetic agents  Coagulations disorders  Cardiovascular effects  Electrolyte disturbances
Prolongation of Anesthetic Agents
Hepatotoxicity  Endocrine effects The American Society of Anesthesiologists does not have an official guideline, but it recommends that all natural products be discontinued 2 to 3 weeks before elective surgery.
Valerian, kava, ginseng, and St. John’s wort are among the more commonly used botanicals that may prolong the effects of anesthetic agents. Valerian has sedative effects that are believed to be mediated by benzodiazepine and γ -aminobutyric acid (GABA) receptors. For patients who use valerian on a daily basis, it is suggested that it be tapered off over the weeks preceding the surgery. Kava is mediated by GABA receptors and potentiates the sedative effects of anesthetics. The general recommendation is to discontinue its use 24 hours before surgery. St. John’s wort induces cytochrome P450 enzymes (cyclosporin, indinavir, and warfarin). It modulates the GABA receptor and inhibits the reuptake of serotonin, dopamine, and noradrenaline. The recommendation is to discontinue it 5 days preoperatively.
The following botanicals are associated with hepatotoxicity: kava, red yeast rice (which contains the ingredient in lovastatin), chaparral, valerian, and echinacea. In terms of endocrinologic effects, both chromium and ginseng can cause hypoglycemia. Table 13.13 highlights some of the more commonly used botanicals and vitamins and their possible effects in the surgical patient.
Complementary and The two domains in which there is the most research and the most promise with regard to surgical Alternative Medicine patients are mind–body-based therapies and approaches based in complete systems, specifically Approaches that May oriental medicine and acupuncture.
Benefit the Surgical Patient