Navigation

Homeopathic Medicine List

The purpose of this national multisite study was to investigate surgical outpatient use of complementary and alternative medicine (CAM) during the two weeks before surgery. The study used a descriptive design consisting of a self-report questionnaire. (1)

RESEARCH QUESTIONS

The following research questions were addressed in this study.

* What is the incidence of preoperative CAM (ie, herbs, vitamins, dietary supplements, homeopathic medicines) use by. surgical patients?

* What is the frequency of surgical patient use of CAM that may interact with the anesthetic and subsequently alter hemostasis?

* What are the demographic characteristics of patients who report preoperative use of CAMs that may cause potential anesthetic-drug interactions resulting in excessive surgical bleeding?

SIGNIFICANCE TO NURSING

Considering that more than 28 million surgical procedures are performed annually in the United States, (2) a significant number of surgical patients may be consuming CAM preoperatively. The use of dietary supplements and herbal medicines has a growth rate of more than 10% per year, with herb and dietary supplement sales exceeding $17 billion in 2000. (3) Patients who use CAM preoperatively may be at increased risk for anesthetic-drug interactions. Herbs used for a specific purpose can produce unintended side effects and lead to toxic interactions when combined with other medications. The American Society of Anesthesiologists (ASA) recommends discontinuing use of herbal medicines at least two weeks preoperatively and warns that certain herbs can prolong the effects of anesthesia, increase the risk of bleeding, or raise blood pressure. (4)

LITERATURE REVIEW

Between 1990 and 1997 in the United States, the use of herbal medicines increased 380%, and the use of vitamins increased 130%. (5) Researchers from Harvard Medical School, Boston, report 22% of surgical patients take medicinal herbs, (6) and researchers in Texas found that 32% of preoperative patients consume botanical medicines. (7) A research study conducted at the University of Colorado, Denver, in 1999 found that 51% of surgical patients take up to 22 alternative medicines per patient, and 24% consume herbs. (8)

Anesthetics may interact with particular herbs, vitamins, or dietary supplements and result in increased surgical bleeding. (9) In a retrospective survey of adverse surgical outcomes in hospitals in Colorado and Utah, postoperative bleeding, the third most frequent adverse surgical event, accounted for 10.8% of all surgical adverse events, with an incidence of 47 per 10,000. (10) Excessive postoperative bleeding may be associated with the preoperative consumption of garlic, ginkgo, and multiple herb-drug combinations. Surgical cancellations because of abnormal coagulation laboratory analyses have been caused by the preoperative consumption of ginkgo, kava kava, St John's Wort, and feverfew. (11)

Case reports of herb-drug interactions often are sketchy. In a systemic review, 68.5% of herb-drug interaction case reports were "unable to be evaluated" because reliability was impeded. (12) Herb-drug interactions may be underreported in the literature because "too little is known about the consequences of interactions." (13) Human clinical trials and case reports of herb research may differ from in vitro or in vivo studies. Research on isolated components of herbs may reveal diverse potential for drug interactions. (14)

Consumers may believe that herbs are safe, natural substances. Botanical medicines, however, may have potent pharmacological effects, be of poor quality, be adulterated or contaminated, or vary in potency. (15) The 1994 Dietary Supplement Health and Education Act does not require manufacturers to provide explicit labeling about contraindications, medication interactions, side effects, or toxicities or to prove product safety or efficacy. (16)

Although most individuals who use alternative therapies combine them with conventional medicine, (17) the use of CAM often is not revealed to physicians. (18) Seventy percent of surgical patients who reported preoperative herb use in a survey also revealed that they did not disclose use to anesthesia care providers, (19) Orthodox practitioners often are not educated about alternative or indigenous medicines; therefore, "the consequences of ignorance will lead to adverse interactions in most cases." (20)

One group of researchers estimates that 15 million people in the United States are at risk for adverse interactions between CAM and other medications. Alternative medicine use is not limited to particular regions or demographics, but alternative medicines are used most often by college-educated Caucasian women older than 50 years of age. (21) The national incidence of surgical patient use of alternative medicines has not been reported previously in the United States; therefore, the scope, significance, and patterns of CAM use and its potential to cause anesthetic interactions that may alter hemostasis have not been determined.

DEFINITION OF TERMS

In this study, CAM includes herbs, dietary supplements, vitamins, and homeopathic medicines that typically are not prescribed by conventional Western physicians. (22) Herbs are defined as medicines that are part of wood and herbaceous plants. They are available without prescription in the form of teas, liquid extracts, powders, tablets, or capsules. (23) Dietary supplements are defined as products that increase total dietary intake. They are not represented as a conventional food or the sole item of a meal. Supplements contain "concentrate, metabolite, constituent, extract, or combination of any ingredient" of a vitamin, mineral, amino acid, enzyme, or herb and are ingested in the form of a capsule, powder, soft gel, or gelcap. (24) Vitamins are defined as supplements considered to contain essential organic compounds or nutrients that are required in small amounts to maintain body functions. (25) Homeopathic medicines are defined as medicines derived from plant, mineral, or animal products. They stimulate natural defenses in very diluted doses but in larger doses may cause overdose or symptoms similar to those that the person taking the medicine currently is experiencing. (26) Complementary and alternative medicines that may interact with other medications to inhibit coagulation are those herbs, dietary supplements, vitamins, or homeopathic medicines that alter primary hemostasis in the coagulation cascade through inhibition of platelet aggregation; particular botanicals containing coumarin derivatives that impede vitamin K-induced synthesis; or herbs that inhibit fibrinolysis. (27)

METHODS

The study used a simple observational descriptive design consisting of a self-report questionnaire that explored participants' CAM use and elicited demographic information, including age, gender, education level, race, surgical subspecialty, and ASA health status. Adapted from the ASA criteria, self-report health status was defined as

* ASA I--a normal healthy patient;

* ASA II--a healthy patient who is a smoker or who has mild disease;

* ASA III--a patient with severe disease that limits activities of daily living; and

* ASA IV--a patient with severe disease that is a constant threat to life. (28)

A purposive sample of investigational settings was drawn from a list of settings throughout the nation. Institutional sites were chosen that were staffed with experienced researchers who were members of the American Association of Nurse Anesthetists (AANA). Certified RN anesthetist (CRNA) investigators from 16 institutions in 15 cities helped collect data. Freestanding surgery centers were excluded to ensure inclusion of a broad range of patients with ASA I to ASA IV health stares. Hospital size, number of surgeries performed per month, and Medicare and Medicaid mix varied among institutions. Seventy percent of participating sites were university institutions, 27% were community hospitals, and 3% were corporate medical centers. Hospital size ranged from 100 to 500 beds (ie, 61%), 500 to 1,000 beds (ie, 27%), and 1,000 to 1,500 beds (ie, 12%) (Table 1).

Sampling technique. After obtaining institutional review board approval from all participating sites, CRNAs collected data by simultaneously surveying randomly selected outpatients undergoing elective procedures. Data were collected from patients at each site about their use of CAM during the two weeks before surgery.

Research instrument. The principle investigator developed the research instrument from a review of the literature and based on a research instrument and CAM database she developed for a previous study. (29) She sought statistical consultation for research instrument design and database variable setup. A panel of CAM experts established face and content validity of the research instrument using a four-point scale of relevance to the domain. Common foods generally were not considered botanical medicines. The three-page research instrument listed the common names of 100 herbs, 47 dietary supplements, 13 vitamins, and 33 homeopathic medicines. The instrument did not solicit data regarding dosage or frequency of use. Variables measured were presented as questions about the use of herbs, dietary supplements, vitamins, and homeopathic medicines, as well as questions about selected demographic variables. The questionnaire allowed for multiple responses regarding alternative medicines taken during the two weeks before surgery.

Data collection procedures. Data were collected from April 2000 through January 2001. Of the 7,500 distributed research instruments, 6,907 (92%) were returned and 6,852 (91%) were valid. At each site, a team of CRNAs and RNs selected participants after reviewing OR schedules and generating a list of potential candidates (ie, English-speaking adults undergoing elective surgery as outpatients). Participants were selected by the toss of a coin to achieve simple random sampling. They were invited to complete questionnaires upon day surgery admission or during the preanesthetic interview. Blinded to the specific objectives of the study, all participants completed the same questionnaire, which had no identifying title. A cover letter that described the purpose of the study and that stated disclosure was anonymous and refusal to participate would not affect care was distributed with the questionnaire. Completion of the questionnaire was considered evidence of participant consent.

Statistical methods. A research assistant scanned all raw data into an SPSS statistical database.(30) The principal investigator and two research assistants twice verified that the information in the database was the same as the actual information submitted by participants. Additional handwritten responses were input into the appropriate institutional database. After initial analyses by the principle investigator, individual institutional databases were distributed to the appropriate CRNA investigator. Institutional data were reexamined before being compiled into a national database. Data from each investigational site and the seven US geographical AANA regions were coded to allow for the identification of each institution and region.

After reviewing the literature, CAMs were classified according to pharmacodynamic coagulation effects to predict potential anesthetic-drug interactions. The literature review consisted of a search of reputable pharmacognosy texts; a review of personal files; and a review of the National Center for Complementary and Alternative Medicine CAM Citation Index, MEDLINE, International Pharmaceutical Abstracts, and PubMed databases for the period 1990 through 2000. The principal investigator and a herbal toxicologist researched pharmacodynamic coagulation classifications. (31) Of the 193 CAMs listed on the research instrument, 24 (12.4%) were classified as having inhibitory effects on coagulation.

The alternative medicines were grouped by syntax definitions and categorized as discrete nominal variables to calculate the incidences of variables counted within cases. A statistician verified variable and syntax definitions, and then performed demographic analyses after importing data from SPSS into an SAS statistical program. (32) This is a standard research technique used to minimize inflation of statistical significance in large database manipulation. Data were analyzed using simple frequencies of CAM use and categories of herbs, vitamins, dietary supplements, and homeopathic medicines, as well as cross-tabulations of categories of CAM with coagulation effects. Pearson's chi-square tests of independence were used to assess the relationship of categories of CAM use and demographic variables; P values < .05 were considered significant.

RESULTS

The sample was 42.4% female and 53.9% male. The mean age of participants was 51 years. The ages of participants were split almost evenly between the 18 to 40 years of age category and the 41 to 90 years of age category. Other participant demographic data can be found in Table 2.

Use of all types of CAM. Sixty-seven percent of participants reported using CAM, ranging from 43% of participants in Augusta, Ga, to 77% of participants in Ft Collins, Colo. Use of multiple combinations of alternative medicines, ranging between two and 83 per participant, was reported by 49% of participants.

Chi-square cross tabulations revealed that participants reporting preoperative consumption of various types of CAM were significantly more likely to be women (70.4%) than men (62.0%) ([X.sup.2.sub.1] = 48.79, P < .001). Participants who use CAM were significantly more likely to be older than age 40 (72.1%) versus younger than age 40 (60.2%) ([X.sup.2.sub.1] = 102.07, P < .001) and more likely to be Caucasian (69.6%) than another race (57.2%) ([X.sup.2.sub.1] = 63.15, P < .001). Participants reporting use of CAM were significantly more likely to be college-educated (73.0%) compared to those who did not report CAM use (61.7%) ([X.sup.2.sub.1] = 88.64, P < .001). There was no difference in CAM use among participants who were classified as ASA I (68.1%) and those classified ASA II (63.0%); however, participants classified as ASA III (68.9%) were significantly more likely to report CAM use than participants classified as ASA IV (64.8%) ([X.sup.2.sub.3] = 16.56, P < .009). Participants consuming CAM preoperatively were significantly more likely to have been admitted for neurosurgery (65.8%) than for other types of procedures ([X.sup.2.sub.1] = 5.31, P = .021).

Use of herbs. Twenty-seven percent of participants reported preoperative use of medicinal herbs. Herb use ranged from 13% of participants in Winston-Salem, NC, to 37% of participants in Denver. Sixteen percent of participants reported using multiple botanic medicines, ranging from Two to 36 herbs. Of the 101 different herbs reported, me most commonly consumed were garlic (9.5%), herbal teas (8.1%), cranberry (5.2%), ginkgo (4.6%), ginseng (4.2%), echinacea (4.1%), and products containing ephedra (3.2%). Chi-square analysis revealed that participants consuming herbs preoperatively were more likely to have been admitted for obstetrical or gynecological surgery (30.1%) than for other types of procedures ([X.sup.2.sub.1] = 4.14, P = .042).

Use of dietary supplements. Thirty-nine percent of participants consumed dietary supplements, ranging from 16% of participants in Augusta to 51% in Ft Collins. Twenty percent of participants combined between two and 35 dietary supplements. Of the 56 types of dietary supplements reported, those used most often were calcium (21.5%), iron (7.0%), glucosamine (6.9%), zinc (5.5%), magnesium (4.7%), potassium (4.3%), and chondroitin (4.0%). Participants who consumed dietary supplements were more likely to be scheduled for obstetrical or gynecological surgery (43.2%) than for other types of surgery ([X.sup.2.sub.1] = 5.94, P = .015). Dietary supplement use also was associated with significant differences among participants undergoing cardiac or thoracic surgery (47.9%) ([X.sup.2.sub.1] = 6.26, P = .012), participants undergoing orthopedic surgery (42.1%) ([X.sup.2.sub.1] = 4.44, P = .035), and participants undergoing neurosurgery (35.5%) ([X.sup.2.sub.1] = 17.32, P < 00.1).

Use of vitamins. Fifty-four percent of participants reported using vitamins. Vitamin use ranged from 30% of participants in Augusta to 67% in Ft Collins. Twenty-eight percent of participants combined from two to 13 vitamins. The most commonly consumed were multivitamins (37.5%), vitamin E (23.3%), and vitamin C (21.4%). Participants consuming vitamins preoperatively were significantly more likely to have been admitted for neurosurgery (53.1%) than for other types of procedures ([X.sup.2.sub.1] = 4.97, P = .025).

Use of homeopathic medicines. One percent of participants disclosed preoperative use of homeopathic remedies. The use of homeopathic medicines ranged from 0% of participants in Richmond, Va, and Pasadena, Calif, to 3% of participants in Albany, NY, and Los Angeles. Use of 26 types of homeopathic medicines was reported, with the most frequently used being arnica (0.5%). Additionally, 0.2% of participants combined two to nine homeopathic medicines.

Use of CAM that may affect coagulation. Complementary and alternative medicines that potentially may interact with anesthetics and inhibit coagulation (33) were taken preoperatively by 34% of participants, ranging from 19% of participants in Augusta to 45% in Rochester, Minn. Thirteen percent of participants combined from two to seven alternative medicines that inhibit coagulation. Table 3 displays percentages of participants' preoperative use of alternative medicines that potentially may interact with traditional medications due to pharmacodynamic coagulation effects.

Participants consuming CAM with the potential to cause anesthetic interactions that may alter hemostasis were more likely to be older than age 40 (41.1%) compared to younger than age 40 (26.5%) ([X.sup.2.sub.1] = 122.09, P < .001); Caucasian (36.7%) compared to another race (26.0 %) ([X.sup.2.sub.1] = 48.11, P < .001); and college-educated (39.3%) compared to having no college education (30.5%) ([X.sup.2.sub.1] = 51.79, P = .02). Participants who consumed CAMs that inhibit coagulation were significantly more likely to have a health status of ASA IV (34.6%) than ASA III (31.5%) ([X.sup.2.sub.1] = 17.29, P < .001).

DISCUSSION

The use of CAM by participants in this study was noted to be higher than use reported in previous studies, (34) which may reflect general societal trends and the increasing use of CAM. (35) The use of herbs, vitamins, and dietary supplements was reported in large numbers, and CAM was used in multiple combinations by many participants in this study. Although the use of multiple types of homeopathic remedies was reported, their use was reported infrequently.

Similar to participants in another national study of CAM use in the United States, (36) participants in this study who consumed CAM were likely to be Caucasian college-educated women older than age 40. The use of herbs and dietary supplements was most prevalent among participants undergoing obstetrical/gynecological or neurosurgical procedures; therefore, these participants may be at higher risk for interactions that alter hemostasis and promote blood loss.

More than 33% of participants reported preoperative use of alternative medicines that may inhibit coagulation and use of multiple combinations of these medicines, which suggests that excessive surgical bleeding caused by anesthetic-drag interactions may be an underreported risk for surgical patients. Surgical patients may not report the use of alternative medicines; therefore, anesthesia care providers may not be informed or educated to avoid administration of contraindicated anticoagulant or anti-inflammatory medications.

Although ginkgo, bromelain, ginger, and vitamin E, along with selected other CAMs, may have potential therapeutic benefits for surgical patients, (37) caution concerning the inhibitory coagulation effects of herbal and alternative medicines is clinically relevant and warranted. Primary hemostasis, coagulation, and fibrinolysis are processes of the coagulation cascade that may be inhibited by CAM use. (38) Excessive blood loss during surgical procedures may cause hemodynamic instability with increased cardiac output, redistribution of blood flow to vital organs, impaired oxygen delivery, increased oxygen consumption and demand, and decreased coronary reserve, and it may predispose shock. Surgical hemorrhage may be treated with blood products; however, blood incompatibility, hemolytic transfusion reaction, citrate intoxication, acid-base changes, decreased 2,3 di-phosphoglycerate, hyperkalemia, volume overload, hypothermia, micro-aggregate delivery, or dilutional coagulopathy may occur. Infections associated with blood product administration include HIV, cytomegalovirus, hepatitis, and potential bacterial infections. (39) Perioperative nurses should be cautious about patients' use of CAM because it can lead to unnecessary administration of blood products for the treatment of excessive surgical hemorrhage.

LIMITATIONS

This study's significance may be restricted by several factors inherent in the research design. The data collection settings were limited to hospitals and did not include freestanding surgery centers. Surgical patients may or may not have been cognizant of the ASA recommendation to discontinue herb use preoperatively. Surgical outcome and anesthetic complication data were not collected; therefore, the clinical significance of potential anesthetic interactions cannot be determined.

The research instrument did not list all known commercial product names, alternative medicines, and exact scientific names of the corresponding herbs, nor did it solicit data regarding dosage and frequency of CAM use. Consequently, omissions, erroneous participant disclosure, or errors of conclusion may have occurred. Participants' self-report of ASA health status may have been inaccurate because of participants' subjective opinion of their health or misinterpretation of ASA health status options listed on the instrument. The literature search may not have been comprehensive of in vitro, in vivo, or clinical research regarding the pharmacodynamic inhibitory coagulation effects of CAM. Additionally, a reliability estimate for the use of the instrument in this sample was not calculated.

IMPLICATIONS

Society's increasing use of CAM is a driving impetus for further research regarding patient risks and for the development of formal practice guidelines. This study emphasizes the critical need for perioperative nurses to educate surgical patients about how the preoperative use of CAM can affect surgical outcomes. Nurses should recommend that surgical patients disclose preoperative use of CAM and should encourage patients to discontinue using alternative medicines that have effects on coagulation. Patients taking herbs, vitamins, dietary supplements, or homeopathic medicines that inhibit coagulation should be questioned about their tendencies to bleed and bruise. If alternative medicines are combined with anti-inflammatory analgesics or anticoagulant medications, laboratory tests, such as international normalized ratio, prothrombin time, and partial thromboplastin time, may be indicated preoperatively. In patients who exhibit increased bleeding times, elective surgery should be postponed until clotting returns to normal, which may take two weeks.

Surgical patient disclosure of preoperative CAM use is necessary. Due to inadequate physician-patient communication and few accurate consumer sources of information about anesthetic interactions, nurses should be accepting of patient use of alternative medicines in an effort to encourage disclosure. Nurses should explain to patients that CAM use potentially may cause anesthetic interactions or predispose surgical bleeding. Nurses can write legislators to encourage governmental regulation of alternative medicines, specifically asking them to require manufacturers to disclose on product labeling the potential for interactions with anesthetics. Further exploration of US surgical patient use of CAM that may produce

* pharmacodynamic sedative effects,

* pharmacodynamic cardiovascular effects,

* pharmacodynamic electrolyte effects, or

* pharmacokinetic effects on the hepatic metabolism of anesthetics is indicated.

SUMMARY

Complementary and alternative medicine use was widespread among the participants in this multisite study of surgical outpatients. Sixty-seven percent of participants reported using CAM during the two weeks before undergoing surgery. Although the use of homeopathic remedies was reported by only 1% of participants, more than 25% consumed herbs preoperatively, almost 40% took dietary supplements preoperatively, and more than 50% used vitamins in the two weeks before surgery. More than 33% of participants reported preoperative use of CAMs that are recognized to inhibit the coagulation cascade and predispose interactions that may cause excessive surgical bleeding. College-educated Caucasian females older than 40 years of age and participants who underwent obstetrical/gynecological or neurosurgical procedures were more likely to use CAM than other participants. As influential leaders charged with protecting surgical patient safety, perioperative nurses can guide surgical patients by encouraging disclosure of CAM use and disseminating accurate information about alternative medicines that may interact with anesthetics.

Editor's note: This study was funded by a grant from the AORN Foundation and Sigma Theta Tau International Honor Society of Nursing. The author's institutional predoctoral training is provided through a National Research Service Award funded by the National Center for Complementary and Alternative Medicine and the National Heart, Lung and Blood Institute (HL T32 07085). Francis Brinker, ND, was consulted as an herbal toxicologist. Carol Vojir, PhD, provided statistical consultation for research instrument development and supervision of teleform scanning. Julalak Baramee, RN, scanned data into the statistical database, Jamie Burke, RN, and Christine Martin verified accuracy of the data with statistical databases. David A. Young, PhD, performed statistical analyses. The following nurse anesthetist researchers and students diligently collected data as site investigators: Kasey Bensky, RN, MSNA, CRNA; Rita Blasier, RN, MSN, CRNA; Chuck Biddle, RN, PhD, CRNA; Ashley Childers, RN, BSN; Daniel McDounough, BS; Michael Dosch, RN, MS, CRNA; Kathleen Fagerland, RN, PhD, CRNA; Jo Anne Fletcher, RN, EdD, CRNA; Lisa Marek RN, BSN; Michelle Gold, RN, PhD, CRNA; Mary E. Shirk Marienau, RN, MS, CRNA; Rex A. Marley, RN, MS, CRNA, RRT; Denise Martin-Sheridan, RN, EdD, CRNA; John J. Nagelhout, RN, PhD, CRNA; Jennifer A. Reed, RN, CRNA; Eric Silvestri, RN, BSN; Diane Willey, RN, CRNA; Wando Wilson, RN, PhD, CRNA; Kathleen Wren, RN, PhD, CRNA; and Karen Zaglaniczny, RN, PhD, CRNA.

Table 1
REGIONAL AND INSTITUTIONAL SITE REPRESENTATION

American
Association                                               Number of
of Nurse                                                  surgeries
Anesthetists                                Number of     performed
region         Location                       beds         monthly

I              Albany, NY                      740          1,500
I              Exeter, NH                      100            400
II             Augusta, Ga                     400          1,200
II             Richmond, Va                  1,058          1,058
II             Winston-Salem, NC               880            880
III            Grosse Pointe Woods, Mich       920          4,000
III            Pontiac, Mich                   500          1,250
IV             Minneapolis                     361            707
IV             Rochester, Minn               1,951          2,578
V              Denver                          393            670
V              Ft Collins, Colo                235            883
V              Los Angeles--site 1             225            675
V              Los Angeles--site 2             850          3,000
V              Pasadena, Calif                 400            500
VI             Cincinnati                      250          1,000
VII            Houston                         257       ([dagger])

                                           Percentage
American                                   of surgical
Association                                procedures
of Nurse                                   covered by
Anesthetists                                Medicare     Instruments
region         Location                    or Medicaid    collected

I              Albany, NY                      25            498
I              Exeter, NH                      34            471
II             Augusta, Ga                     35            487
II             Richmond, Va                    34            303
II             Winston-Salem, NC               27            500
III            Grosse Pointe Woods, Mich       37            432
III            Pontiac, Mich                   31            500
IV             Minneapolis                      *            495
IV             Rochester, Minn                 45            495
V              Denver                          19            496
V              Ft Collins, Colo                40            501
V              Los Angeles-site 1              40             75
V              Los Angeles--site 2             50            499
V              Pasadena, Calif                 10            194
VI             Cincinnati                      70            501
VII            Houston                     ([dagger])        460

* Veterans affairs hospital

([dagger]) Missing data

Table 2
PARTICIPANT DEMOGRAPHIC DATA

Gender *
Female                              42.4%
Male                                53.9%

Age ([dagger])
Mean                                51 years
Median                              50 years
Mode                                53 years
Standard deviation                  17 years
18 to 40 years of age               46.6%
41 to 90 years of age               49.2%

Education level ([double dagger])
No college                          53.9%
Some college                        43.6%

Race ([section])
Caucasian                           74.6%
Other                               18.9%

Health status ([parallel])
American Society of
Anesthesiologists (ASA) I           59.5%
ASA II                              24.9%
ASA III                              9.6%
ASA IV                               2.3%

Type of procedure ([paragraph])
Orthopedic                          16.5%
General surgery                     14.7%
Otorhinolaryngology                 13.1%
Obstetrics/gynecology               11.1%
Urology                              8.6%
Neurosurgery                         4.5%
Ophthalmology                        4.0%
Other                               24.3%

* Not disclosed by 3.5% of
participants.

([dagger]) Not disclosed by 4.2% of
participants.

([double dagger]) Not disclosed by 2.4% of
participants.

([section]) Not disclosed by 6.4% of
participants.

([parallel]) Not disclosed by 3.6% of
participants.

([paragraph]) Not disclosed by 3.2% of
participants.

Table 3
PARTICIPANT USE OF COMPLEMENTARY AND ALTERNATIVE
MEDICINES THAT POTENTIALLY CAN INHIBIT COAGULATION

                   Percentage of
Medicine          participant use  Effects

Bromelain               0.2        Inhibits platelet aggregation,
                                   inhibits fibrin formation

Borage                  0.2        Inhibits platelet aggregation

Cayenne                 1.4        Inhibits platelet aggregation,
                                   inhibits fibrin formation

Celery                  4.2        Inhibits platelet aggregation,
                                   contains coumarins

Chamomile               2.0        Inhibits platelet aggregation

Dandelion               0.3        Inhibits platelet aggregation

Dong quai               0.3        Inhibits platelet aggregation,
                                   contains coumarins

Evening primrose        0.7        Inhibits platelet aggregation,
                                   increases bleeding time (BT)

Fenugreek               0.2        Contains coumarins

Feverfew                0.3        Inhibits platelet aggregation

Fish oil                2.1        Inhibits platelet aggregation,
                                   increases BT

Garlic                  9.5        Inhibits platelet aggregation,
                                   inhibits fibrin formation,
                                   increases BT

Ginger                  2.7        Inhibits platelet aggregation

Ginkgo                  4.6        Inhibits platelet aggregation,
                                   inhibits platelet activating
                                   factor

Ginseng                 4.2        Inhibits platelet aggregation,
                                   inhibits fibrin formation

Hawthorn                0.2        Inhibits platelet aggregation

Horse chestnut          0.1        Inhibits platelet aggregation,
                                   contains coumarins

Huang qi                0.2        Inhibits platelet aggregation

Kava kava               1.0        Inhibits platelet aggregation

Licorice                1.2        Inhibits platelet aggregation,
                                   contains coumarins

Papain                  0.1        Inhibits platelet aggregation

Red clover              0.2        Inhibits platelet aggregation,
                                   contains coumarins

Turmeric                0.3        Inhibits platelet aggregation

Vitamin E              23.3        Inhibits platelet aggregation

NOTES

(1.) P J Brink, M J Wood, "Descriptive designs," in Advanced Design in Nursing Research, second ed, P J Brink, M J Wood, eds (Thousand Oaks, Calif: Sage Publications, 1998) 287-307.

(2.) "National hospital discharge survey: 1998 Summary," Centers for Disease Control and Prevention, http://www.cdc.gov/nchs/products/ pubs/pubd/ad/311-320/ad316.htm (accessed 26 Sept 2002).

(3.) Consumer Use of Dietary Supplements (Emmaus, Pa: Prevention Magazine, 1999).

(4.) P S Weintraub, "New and old media used to distribute ASA's patient safety message about herbal medications," ASA Newsletter (July 1999); "What you should know about herbal use and anesthesia," American Society of Anesthesiologists, http://www.asahq/org/ PublicEducation/insidherb.html (accessed 4 Oct 2002).

(5.) D M Eisenberg et al, "Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey," JAMA 280 (Nov 11, 1998) 1569-1575.

(6.) L C Tsen et al, "Alternative medicine use in presurgical patients," Anesthesiology 93 (July 2000) 148-151.

(7.) A D Kaye et al, "Herbal medicines: Current trends in anesthesiology practice--a hospital survey," Journal of Clinical Anesthesia 12 (September 2000) 468-471.

(8.) C L Norred, S Zamudio, S K Palmer, "Use of complementary and alternative medicines by surgical patients," AANA Journal 68 (February 2000) 13-18.

(9.) Ibid; C L Norred, "Herbs and anesthesia," Alternative Therapies in Women's Health 3 (April 2001)26-30; C L Norred, F Brinker, "Potential coagulation effects of preoperative complementary and alternative medicines," Alternative Therapies in Health and Medicine 7 (November/ December 2001) 58-67.

(10.) A A Gawande et al, "The incidence and nature of surgical adverse events in Colorado and Utah in 1992," Surgery 126 (January 1999) 66-75.

(11.) Norred, "Herbs and anesthesia," 26-30.

(12.) A Fugh-Berman, E Ernst, "Herb-drug interactions: Review and assessment of report reliability," British Journal of Clinical Pharmacology 52 (November 2001) 587-595.

(13.) P A G M DeSmet, P F D'Arcy, "Drug interactions with herbal and other non-orthodox remedies," in Mechanisms of Drug Interactions. Handbook of Experimental Pharmacology, vol 122, ed P F D'Arcy, J C McElnay, P G Welling (Springer: New York, 1996) 327-352.

(14.) Norred, Blinker, "Potential coagulation effects of preoperative complementary and alternative medicines," 58-67; F J Brinker, Herb Contraindications and Drug Interactions: With Extensive Appendices Addressing Specific Conditions, Herb Effects, Critical Medications, and Nutritional Supplements, third ed (Sandy, Ore: Eclectic Medical Publications, 2001) 25.

(15.) L G Miller et al, "White paper on herbal products. American College of Clinical Pharmacy," Pharmacotherapy 20 (July 2000) 877-891; E Ernst, "Harmless herbs? A review of the recent literature," American Journal of Medicine 104 (February 1998) 170-178.

(16.) "Food labeling; Requirements for nutrient content claims, health claims, and statements of nutritional support for dietary supplements; Final rule," Federal Register 62 (Sept 23, 1997) 4985949868; M J Cupp, ed, Toxicology and Clinical Pharmacology of Herbal Products (Towanta, NJ: Humana Press, 2000) 3-8.

(17.) Eisenberg et al, "Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey," 1569-1575; J A Astin, "Why patients use alternative medicine. Results of a national study," JAMA 279 (May 20, 1998) 1548-1553.

(18.) Eisenberg et al, "Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey," 1569-1575; J Gulla, A J Singer, "Use of alternative therapies among emergency department patients," Annals of Emergency Medicine 35 (March 2000) 226-228; L VandeCreek, E Rogers, J Lester, "Use of alternative therapies among breast cancer outpatients compared with the general population," Alternative Therapies in Health and Medicine 5 (January 1999) 71-76; S J Weiss, K M Takakuwa, A A Ernst, "Use, understanding, and beliefs about complementary and alternative medicines among emergency department patients," Academic Emergency Medicine 8 (January 2001) 41-47.

(19.) Kaye et al, "Herbal medicines: Current trends in anesthesiology practice--a hospital survey," 468-471.

(20.) K Chan, L Cheung, eds, Interactions Between Chinese Herbal Medicinal Products and Orthodox Drugs (Amsterdam: Harwood Academic, 2000) 102.

(21.) Eisenberg et al, "Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey," 1569-1575.

(22.) "What is CAM?" National Center for Complementary and Alternative Medicine, http://nccam .nih.gov/clinicallxials/factsheet/index. htm#1 (accessed 21 Oct 2002).

(23.) Brinker, Herb Contraindications and Drug Interactions: With Extensive Appendices Addressing Specific Conditions, Herb Effects, Critical Medications, and Nutritional Supplements, third ed, 25.

(24.) "What are dietary supplements?" National Institutes of Health, Office of Dietary Supplements, http://ods.od.nih.gov/whatare/whatare .html (accessed 21 Oct 2002).

(25.) "General information," US Pharmacopoeia, http://www.usp.org /information/just_ask/vitamin1.htm (accessed 26 Sept 2002).

(26.) D Ullman, "Ten most frequently asked questions on homeopathic medicine," Homeopathic Educational Services, http://www .homeopathic.com/intro/tenques.htm (accessed 26 Sept 2002).

(27.) Norred, Brinker, "Potential coagulation effects of preoperative complementary and alternative medicines," 58-67.

(28.) R A Marley, M J Kremer, S L Alves, "Preoperative evaluation and preparation of the patient," in Nurse Anesthesia, second ed, J J Nagelhout, K L Zaglaniczny, eds (Philadelphia: WB Saunders, 2001) 308-348.

(29.) Norred, Zamudio, Palmer, "Use of complementary and alternative medicines by surgical patients," 13-18.

(30.) SPSS--Statistical Package for the Social Sciences, 10.0 (Chicago: SPSS, Inc, 1999).

(31.) Norred, Brinker, "Potential coagulation effects of preoperative complementary and alternative medicines," 58-67.

(32.) SAS--Statistical Analysis System, 8.0 (Cary, NC: SAS Institute, Inc, 1999).

(33.) Norred, Brinker, "Potential coagulation effects of preoperative complementary and alternative medicines," 58-67.

(34.) Tsen et al, "alternative medicine use in presurgical patients," 148-151; Kaye et al, "Herbal medicines: Current trends in anesthesiology practice--a hospital survey," 468-471; Norred, Zamudio, Palmer, "Use of complementary and alternative medicines by surgical patients," 13-18.

(35.) Eisenberg et al, "Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey," 1569-1575.

(36.) Ibid.

(37.) Norred, "Herbs and anesthesia," 26-30; J J Perry, "Surgery and complementary therapies: A review," Alternative Therapies in Health and Medicine 6 (September 2000) 64-74.

(38.) Norred, Brinker, "Potential coagulation effects of preoperative complementary and alternative medicines," 58-67.

(39.) P G Barrash, B F Cullen, R K Stoelting, eds, Clinical Anesthesia, fourth ed (Philadelphia: Lippincott Williams & Wilkins, 2001) 201-236.

Carol L. Norred, RN, MHS, CRNA, is a nurse anesthetist and clinical instructor in the Department of Anesthesiology and a doctoral student in the School of Nursing at the University of Colorado Health Sciences Center, Denver.

COPYRIGHT 2002 Association of Operating Room Nurses, Inc.
COPYRIGHT 2003 Gale Group