Prior to surgery, patients must undergo a routine pre-operative evaluation by an anesthesiologist. As more people have begun taking herbal remedies, this has become an increasingly important safety issue.
By: Dr. Jennifer Hirsh
Every year in the United States, approximately 28 million surgical procedures are performed.
Prior to surgery, patients must undergo a routine pre-operative evaluation by an anesthesiologist. This evaluation can be done anytime from two months before the surgery to the day of the surgery.
If possible, it is in the patient’s best interest to schedule the pre-admission testing at least one-two weeks before the surgery date. This allows the patient time to ask questions, donate their own blood if necessary, and stop taking certain herbal and over-the-counter remedies that can interfere with the anesthesia. As more people have begun taking herbal remedies, this last step has become an increasingly important safety issue.
Healthy patients account for 80 percent of all surgeries and the mortality rate among these patients is extremely low, ranging from 0 to 0.7 percent. However, for both healthy and unhealthy patients, there are several risk factors that a pre-operative evaluation can identify.
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‘For anyone who is planning to undergo surgery, help your anesthesiologist help you by scheduling your pre-operative evaluation in a timely manner and by being forthright with your physician about what you are putting into your body.’ Dr. Jennifer Hirsh
Anesthesiologist The Medical Center at Princeton |
When the patient arrives for pre-admission testing, a nurse will meet with the patient to start a nursing assessment, begin pre-operative teaching, check that necessary tests are ordered and take an accurate weight. It is extremely important to have an accurate body weight because the intravenous drug dosage that will be used during the surgery is based on weight.
Once the nurse is finished with this interview, the patient will meet with the anesthesiologist who will:
talk with the patient about what to expect and investigate if there are potential problems;
find out if there is a past history of problems with anesthesia, either in the patient’s background or in the patient’s immediate family;
find out any and all medications that the patient is taking from herbal supplements to aspirin to alcohol;
perform a physical exam, evaluating the heart, lungs, airway and any other areas based on the patient’s history.
For patients who do not see a doctor regularly, this exam may reveal an unknown condition such as asymptomatic hypertension. If the patient’s blood pressure is high (a reading greater than 160/90), the patient may require medication to correct this prior to surgery. The doctor may order a chest X-ray or electrocardiogram, depending on the age and health of the patient.
Typically, the anesthesiologist will spend between 10 and 30 minutes with each patient. Computerization has proved beneficial in this area. In many multi-care systems, such as the one at the Medical Center at Princeton, a patient’s medical record is computerized, and the anesthesiologist has immediate on-screen access to the results of a patient’s history, cardiac stress tests, echocardiograms and pulmonary function tests. This enables the physician to evaluate the patient more thoroughly while easing the patient’s burden of having to recall details of past medical tests.
After the exam is finished, the anesthesiologist will formulate the patient’s health status and give the patient an American Society of Anesthesiologists classification ranging from I-V.
Class I refers to healthy patients with no disease. Class II refers to patients with mild systemic disease. Examples of systemic illness include coronary artery disease, asthma, diabetes and hypertension. Class III refers to patients with severe systemic disease that is not incapacitating. Class IV refers to patients who have an incapacitating disease that is a constant threat to life.
Class V is reserved for patients who are not expected to survive 24 hours, with or without surgery. Once the patient is classified, the physician’s goal is to put the patient in the optimal condition before surgery.
For a significant number of people, putting them in tip-top shape may mean placing them on medication to treat hypertension or asking them to stop smoking, taking aspirin and using herbal medications. This last request is becoming more prevalent and more important.
Because many people equate natural substances with being safe and good for you, they may not think of the possible interactions with anesthetic drugs. Herbs, like manufactured drugs, have chemical properties.
According to the ASA, it is important for patients to realize that herbal products do not undergo the same strict research requirements as prescription drugs or over-the-counter medications. Certain herbal medications prolong the effects of anesthesia, others increase the risk of bleeding or raise blood pressure. Other effects may be more subtle, and if the anesthesiologist knows what the patient has been ingesting, he or she can anticipate a possible reaction.
To guide patients and physicians alike, the ASA has produced a list of commonly used herbs, their uses and possible side effects or drug interactions:
Echinacea used to boost the immune system, help fight colds and flu, and aid wound healing. It may cause inflammation of the liver if used with certain other medications such as anabolic steroids, methotrexate, or others.
Ephedra (Ma-Huang) used as an appetite suppressant in many over-the-counter diet aids and for treating asthma or bronchitis. It may interact with certain antidepressant medications or certain high blood pressure medications to cause dangerous elevations in blood pressure or heart rate. It could cause death in certain individuals.
The following four herbs feverfew, garlic, ginger and ginkgo biloba all may increase bleeding, especially in patients already taking certain anticlotting medications. Here are their common uses.
Feverfew used to ward off migraine headaches and for arthritis, allergies and rheumatic disease.
Garlic used for lowering cholesterol, triglyceride levels and blood pressure.
Ginger used for reducing nausea, vomiting and vertigo.
Ginkgo Biloba used to increase blood circulation and oxygenation and for improving memory and mental alertness.
Ginseng used to increase physical stamina and mental concentration. It may cause decreased effectiveness of certain anticlotting medications. It may increase heart rate or high blood pressure. It may cause bleeding in women after menopause.
Goldenseal used as a mild laxative and to reduce inflammation. It may worsen swelling and/or high blood pressure.
Kava-kava used for nervousness, anxiety or restlessness or as a muscle relaxant. It may increase the effects of certain antiseizure medications and/or prolong the effects of certain anesthetics. It can enhance the effects of alcohol. It may increase the risk of suicide for people with certain types of depression.
Licorice used for treating stomach ulcers. Certain licorice compounds may cause high blood pressure, swelling or electrolyte imbalances.
Saw Palmetto used for enlarged prostate and urinary inflammations. It may cause effects with other hormone therapies.
St. John’s Wort used for mild to moderate depression or anxiety and sleep disorders. It may prolong the effects of certain anesthetic agents.
Valerian used as a mild sedative or sleep-aid or as a muscle relaxant. It may increase the effects of certain antiseizure medications or prolong the effects of certain anesthetic agents.
For anyone who is planning to undergo surgery, help your anesthesiologist help you by scheduling your pre-operative evaluation in a timely manner and by being forthright with your physician about what you are putting into your body. Together, you can help make your surgical procedure less stressful and highly successful.
Dr. Jennifer Hirsh is an anesthesiologist on staff at The Medical Center at Princeton. Health Matters appears Fridays in the Lifestyle section of The Princeton Packet and is contributed by The Medical Center at Princeton.