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Herbal medicines and postoperative haemorrhage

A 65-year-old man with gross osteoarthritis of the left hip was prepared for elective total hip arthroplasty. He had a history of chronic obstructive pulmonary disease, early Alzheimer’s dementia and adenocarcinoma of the prostate. He was on oral diclofenac sodium, intramuscular goserelin acetate and a brown liquid herbal medicine (one tablespoon twice a day). At pre-operative assessment the patient was advised to discontinue the herbal and non-steroidal anti-inflammatory medicine 2 weeks prior to surgery. The immediate postoperative period was complicated by an acute wound haemorrhage (750 ml of blood collected via the deep drain and approximately 150 ml discharged into wound dressing over the first 2 h). Crystalloid fluid resuscitation was commenced and a pressure dressing applied. The full blood count confirmed anaemia (haemoglobin concentration, 8 g.dl) and a normal platelet count. A coagulation screen was normal. Discussion with the patient’s wife revealed that he had continued the herbal medication up to the day of surgery, although the diclofenac had been stopped 2 weeks prior to surgery. The herbalist was contacted and confirmed as the active ingredients as Gingko biloba (Ginkgo, Maidenhair tree), Piper Lango (Lang pepper), Tylophora indica (Asthma weed), Marrubium vulgare (Horehound), and Cetaria islandica (Iceland moss). The patient received a 4-unit blood transfusion and the bleeding stopped after about 8 h.The drain was removed at 48 h and the patient went on to make a satisfactory recovery and was discharged from hospital on the fifth postoperative day. Recent surveys in Australia and the United States report that 12–37% of subjects use herbal medications [1, 2]. Although it is customary for a routine drug history to be taken, the majority of patients do not reveal their often longterm intake of herbal medicines. The current recommendation by the American Society of Anesthesiologists is that patients cease herbal medicines at least 2 weeks prior to surgery [3]. Ginkgo biloba extract (GBE) increases the risk of bleeding if used in combination with warfarin, antiplatelet drugs, and certain other medications [4]. Haemorrhage at various anatomical sites has been reported with the ingestion of GBE alone [5–10], or in combination with nonsteroidal therapy [11]. Ginkgo belongs to the Ginkgoaceae taxonomic class of herbs. It is marketed in a number of multi-ingredient preparations under a variety of trade names and is available as tablets, capsules, nutrition bars, sublingual sprays and tinctures. GBE has arterial and venous vasoactive properties that enhance tissue perfusion and cerebral blood flow. The ability of this extract to produce arterial vasodilation, inhibit arterial spasm, decrease capillary permeability and fragility, decrease blood viscosity and erythrocyte aggregation, accounts for its physiological effects, which are probably due to stimulation of prostaglandin synthesis or caused by indirect vasoregulatory effects on catecholamines [12]. Ginkgolide B, a chemical component of the extract, has been identified as a potent inhibitor of platelet activating factor [12]. When the use of herbal medicines is discovered they should be investigated to identify their active components. An explanation of the associated risks with continued ingestion preoperatively is mandatory. We also believe that such medicines prescribed for chronic or malignant disease are less likely to be disclosed by patients prior to surgery and are often not stopped in the pre-operative period. Healthcare workers and clinicians should maintain a high index of suspicion for such patients and obtain a detailed history, specifically addressing herbal medications as part of the pre-operative assessment, particularly in elderly orthopaedic patients with unrelated medical disorders. We recommend that pre-operative assessment clinics have notices in several languages requesting patients to disclose their intake of herbal medicines.