Herbal Remedies, IV Dyes & Electrolytes Flashcards
True or False: Are all supplements benign
False.
True or False: If you eat a well balanced meal you should also take a multivitamin supplement
False.
Complimentary therapy
The addition of non-conventional therapies to accepted treatments
Alternative therapy
The use of nonconventional therapies in lieu of accepted treatments.
Complementary and Alternative Medicine (CAM)
Integrative health or integrative medicine.
This is when complementary approaches are incorporated into mainstream healthcare.
- Visits to CAM practitioners exceed those to primary care physicians
What are the three reasons why we care if CAM is onboard during surgery?
- commonly used herbal medications exhibit direct effects on the cardiovascular system & coagulation systems
- some CAMs interfere with conventional medications that are commonly given in the post-op period
- CAM in the perioperative period is increasingly being described as reducing post-op nausea/vomiting, & pain.
What are the 3 major categories of CAM?
- Natural products: herbs, vitamins/minerals, and probiotics. “dietary supplements”
- Mind-body practices: yoga, chiropractic/osteopathic manipulation, meditation, & massage therapy, acupuncture, relaxation techniques.
- Traditional healers: ayruredic medicine, Traditional Chinese, naturopathy and functional medicine.
Pharmacological effects of Echinacea
- Purple cone-flower root
Effects: activation of cell-mediated immunity
Perioperative concerns with Echinacea?
- Allergic reactions
- Decreases effectiveness of immunosuppressants
- Potential for immunosuppression with long term use
Should you discontinue Echinacea before surgery?
No data;
Pharmacological effects of Ephedra?
Increases HR and BP through direct and indirect sympathomimetic effects*
Perioperative concerns with Ephedra?
- Risk of MI and Stroke from tachycardia and HTN**
- Ventricular arrhythmias with Halothane
- Long-term use depletes endogenous catecholamines and may cause intra-operative hemodynamic instability
- Life threatening interaction with MAOIs
Should you discontinue Ephedra before surgery?
Yes. Discontinue 24hr prior
Pharmacological effects of Garlic
- Inhibits platelet aggregation (may be irreversible)**
- Increases fibrinolysis
- Equivocal antihypertensive activity (controversial)
Perioperative concerns with Garlic
- May increase risk of bleeding - especially combined with other medication that inhibit platelet aggregation**
Should you discontinue Garlic before surgery?
Yes. 7 days prior **
Pharmacological effects of Ginger
- Antiemetic
- Anti-platelet aggregation
Perioperative concerns with Ginger
- May increase risk of bleeding
Should you discontinue Ginger before surgery?
No data
Pharmacological effects of Gingko
- Inhibits platelet- activating factor (inhibits platelet function)
Perioperative concerns with Gingko
- May increase risk of bleeding, especially when combined with other medications that inhibit platelet aggregation
Should you discontinue Gingko before surgery?
Yes. Discontinue 36 hrs prior
Pharmacological effects of Ginseng
- Lowers BG
- Inhibits platelet aggregation (may be irreversible)
- Increased PT/PTT in animals
Perioperative concerns with Ginseng
- Hypoglycemia
- May increase risk of bleeding
- May decrease anticoagulant effects of warfarin
Should you discontinue Ginseng before surgery
Yes. Discontinue 7 days prior
Pharmacological effects of Green Tea
- Inhibits platelet aggregation**
- Inhibits Thromboxane A2 formation**
Perioperative concerns with Green Tea
- May increase risk of bleeding
- May decrease anticoagulant effect of warfarin** (so does ginseng)
Should you discontinue Green Tea before surgery
Yes. 24 hrs prior
Pharmacological effects of Kava
- Sedation
- Anxiolysis
Perioperative concerns with Kava
- May increase sedative effect of anesthetics
- Increase in anesthetic requirements with long term use (unstudied)
(Metabolized by CYP450)
Should you discontinue Kava before surgery
Yes. 24 hrs prior
Pharmacological effects of Saw Palmetto
- Inhibits 5 alpha-reductive
- Inhibits cyclooxygenase
Perioperative concerns with Saw Palmetto
- May increase risk of bleeding
Should you discontinue Saw Palmetto before surgery
No data
Pharmacological effects of St. John’s Wort
- Inhibits neurotransmitter reuptake
- MAO inhibition is unlikely
Perioperative concerns with St. John’s Wort
- Induction of cytochrome P450 enzymes = affects: - cyclosporine - warfarin - steroids - protease inhibitors May affect: - benzodiazepines - calcium channel blockers - Decreased serum digoxin levels - Delayed emergence
Should you discontinue St. John’s Wort before surgery
Yes. 5 days prior
Pharmacological effects of Valerian
- Sedation
Perioperative concerns with Valerian
- May increase sedative effects of anesthetics
- Acute withdrawal after long term use: M&M increase (morbidity & mortality)**
- May increase anesthetic requirements w/ long term use
Should you discontinue Valerian before surgery
No data.
Summary of Herbal effects on anesthesia through what 3 mechanisms
- Direct effects - intrinsic pharmacological effects
- Pharmacological interactions (i.e. alteration of the action of conventional drugs at effector sites)
- Pharmacokinetic interactions (alteration of ADME)
What are the 4 G’s that inhibit platelet function**
- Gingko
- Ginseng
- Garlic
- Green Tea
True or False: Preop discontinuation of all herbal medicines eliminates complications related to their use
False. Discontinuation might not eliminate complications
Withdrawal of which herbal medicine can increase morbidity & mortality?**
Valerian
If your patient presents on the day of surgery for an elective procedure and are non compliant about discontinuing herbal supplements, what should you do?
Anesthesia can usually proceed safely at the discretion of the anesthesia provider
What is the ASA guideline for herbal supplements?
Discontinue two weeks before surgery since there is no official standard or guideline for preop herbal meds
Other herbal medicines in the top 10 list with no reports of ADRs or risks but should be d/c’d 2 weeks before
- Soy
- Isoflavones
- Grape seed extract
- Milk thistle
- Boldo (peumus boldus)
- Danshen
- Papaya
CoenzymeQ10
- Promoted as an antioxidant
- Structurally related to Vit K
- Interacts with Warfarin**
- Endogenous CoQ10 can prevent the membrane transition pore from opening, b/c it counteracts several apoptotic events, such as DNA fragments, cytochrome c release, & membrane potential depolarization
Glucosamine & Chondroitin Sulfate
- Widely used for joint disorders & accepted as OA management
- Glucosamine does interfere w/ Warfarin & w/ some diabetes animal studies
- Should be discontinued 2 two weeks prior to surgery
Pharmacological effects of Fish Oil-omega 3 fatty acid supplement
- Reduce the incidence of may chronic diseases that involve inflammatory processes, including CV ds., IBS, Cancer, RA, & neurodegenerative illness
- Meta analysis concluded that it does not decrease M&M, cardiac death, sudden death, MI or stroke
Perioperative concerns with Fish Oil-omega 3 fatty acid
- Increased risk of bleeding
Should you discontinue Fish Oil before surgery
Yes. D/c 2 weeks before surgery
What is a Prebiotic?
A non-digestible food ingredient that beneficially affects the host by selectively stimulating the growth & activity of one or a limited number of bacteria in the colon that have the potential to improve host health
What is Probiotic
A live microbial feed supplement that beneficially affects the host by improving the intestinal microbial balance
Acupuncture has promising indications for what?
PONV prevention
- the main spot is the P6 or PC6
- tapping a small needle cap over the P6 point (between the palmeris longs and flexor carpi radialis tendons, 4 cm proximal to the distal wrist crease and 1 cm below the skin)
What are the main concerns with IV dyes?
- Can cause allergic reactions
- itching, hives, anaphylactoid & anaphylactic
- more commonly in asthmatics & hx of allergy w/ multi. Comorbidities
- Antigen fixates itself onto mast cells or basophils
= release of histamine & tryptase = inhibit coagulation, dilate blood vessels, release complement or even stimulate IgE reaction
- Extravasation of the intravenous contrast media agent
ICM induced renal impairment can be reduced by using ?
Low-osmolality contrast media & extracellular volume expansion
High-osmolar contrast media (HOCM)
- Contains FEW dissolved particles and iodine atoms.
- Causes a fluid shift from the cell to the vein with the ICM
Low-osmolar contrast media (LOCM)
- Also known as Non-ionized contrast media
- Contains a GREATER number of dissolved particles with iodine.
- This one is closely iso-osmolar inducing less fluid shift from the cell
- More costly so therefore not used as often
Which ICM has lower reactions?
LOCM can still have reactions but fewer occur compared to HOCM
- reactions can occur from a half hour to up to a week after administration
Your diabetic patient is undergoing a CT w/ contrast, what education should you provide?
- Diabetic patients taking Metformin must withhold the medication b/c of the risk of lactic acidosis (mainly if diabetic neuropathy)
- 24 hrs before ICM and hold for 48 hrs after
Who should never receive ICM?
Pregnant patients are an absolute contraindication
To avoid renal issues with ICM how should you prepare your patient?
Hydrate them adequately starting 1 hr before the CT and continue for 24hrs afterward
Patients who are at risk for anaphylactoid reactions with ICM should receive what as pretreatment?
- Corticosteroids: methyprednisolone, or prednisone (PO or IV)
- Severe previous reactions give
- H1 blocker: Benadryl, Diphenhydramine, & - H2 blocker: Cimetidine or ranitidine
What is the most frequently used agent that causes anaphylactoid reactions? How much does it take to cause this reaction?
IV Contrast Media
- takes as little as 1 mL for a patient to have these reactions
Hyponatremia
- Occurs in the presence of low serum osmolality (< 285 mOsm/kg)
- Usual issue is elevated total body water (not enough sodium)
- Causes:
- Hypotonic fluids
- Irrigation (glycine & sorbitol) w/ TURP or hysteroscopy
(= these solutions prevent dispersal of electrical current when mono polar cautery is used.) - Mannitol use with renal dysfunction
Hyponatremia signs and symptoms (
- Nausea/vomiting
- Visual disturbances
- Muscle cramps
- Weakness
- Bradycardia
- May develop increased ICP = mental status changes
- If Na is at 120 mEq/L now at risk for seizures
Hypernatremia
- Less common than hypo
- Always associated with hypertonicity
- Can present with low, normal, or high total body sodium content
- Increases your MAC
- Delay surgery if pt has > 150 mEq/L
Potassium basics
Normal 3.5 - 5 mEq/L
- 2% is extracellular
Hypokalemia
- a low K = significant body depletion of K (GI loss/diarrhea), renal loss, trans cellular shifts, or inadequate intake
- GI Loss:
- Overuse of laxatives
- Acute colonic pseudo-obstruction
- Produces ECG changes:
- ST segment & T wave depression
- Prolonged QT
- U waves
- Cardiac arrhythmias - afib
- PVCs
- Impairs cardiac contractility
Hypokalemia signs and symptoms
- ST segment & T wave depression
- Prolonged QT
- Onset of U waves
- Cardiac arrhythmias: PVCs and afib
- Muscle weakness: including respiratory
= sensitive to muscle relaxants
Hyperkalemia signs & symptoms
- Symptoms start to show @ 5.5 mEq/L
- Profound weakness
- Cardiac conduction abnormalities
- Enhanced automaticity & repolarization irregularities
- PEAKED T WAVE**, widening P wave, lengthening PR segment
Anesthesia concerns with Hyperkalemia
- Do not give succinylcholine will cause K+ to increase by 0.5 mEq/L
- If you have a patient coming in with an acute stroke, burn, or spinal cord injury avoid Sux after 24 hrs
Treatment for Hyperkalemia
- Calcium chloride
- Calcium gluconate
- Kaexylate
- Dialysis
Hypocalcemia Causes
- Hypoparathyroidism
- Hyperphosphatemia
- Vitamin D deficiency
- Malabsorption
- Rapid blood transfusion
- Pancreatitis
- Rhabdomyolysis
- Fat embolism
Hypocalcemia Treatment
- Calcium chloride or gluconate IV
- chloride provides more Ca than gluconate
- gluconate less irritating
Magnesium basics
Serum Mag = 1.3 - 2.2 mEq/L
Hypomagnesemia
- QT prolongation (Torsades de Pointes)
- Muscle weakness tremors
- Twitches
- Numbness
- Paresthesia
- Confusion
- Drowsiness
- Seizure
- increased susceptibility to muscle relaxants
- may remain weak after surgery, can include respiratory insufficiency
Hypermagnesemia
- Very uncommon
- Usually caused by renal dysfunction or excessive intake with is often iatrogenic
- Typical symptoms occur at 4 - 6 mEq/L
