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Context  Widespread use of herbal medications among the presurgical population may have a negative impact on perioperative patient care.

Objectives  To review the literature on commonly used herbal medications in the context of the perioperative period and provide rational strategies for managing their preoperative use.

Data Sources  The MEDLINE and Cochrane Collaboration databases were searched for articles published between January 1966 and December 2000 using the search terms herbal medicine, phytotherapy, and alternative medicine and the names of the 16 most commonly used herbal medications. Additional data sources were obtained from manual searches of recent journal articles and textbooks.

Study Selection  We selected studies, case reports, and reviews addressing the safety and pharmacology of 8 commonly used herbal medications for which safety information pertinent to the perioperative period was available.

Data Extraction  We extracted safety, pharmacodynamic, and pharmacokinetic information from the selected literature and reached consensus about any discrepancies.

Data Synthesis  Echinacea, ephedra, garlic, ginkgo, ginseng, kava, St John's wort, and valerian are commonly used herbal medications that may pose a concern during the perioperative period. Complications can arise from these herbs' direct and pharmacodynamic or pharmacokinetic effects. Direct effects include bleeding from garlic, ginkgo, and ginseng; cardiovascular instability from ephedra; and hypoglycemia from ginseng. Pharmacodynamic herb-drug interactions include potentiation of the sedative effect of anesthetics by kava and valerian. Pharmacokinetic herb-drug interactions include increased metabolism of many drugs used in the perioperative period by St John's wort.

Conclusions  During the preoperative evaluation, physicians should explicitly elicit and document a history of herbal medication use. Physicians should be familiar with the potential perioperative effects of the commonly used herbal medications to prevent, recognize, and treat potentially serious problems associated with their use and discontinuation.

JAMA. 2001;286:208-216

Author Contributions: Study concept and design: Ang-Lee, Moss, Yuan.

Aquisition of data: Ang-Lee, Moss, Yuan.

Analysis and interpretation of data: Ang-Lee, Moss, Yuan.

Drafting of the manuscript: Ang-Lee.

Critical revision of the manuscript for important intellectual content: Ang-Lee, Moss, Yuan.

Obtained funding: Moss, Yuan.

Administrative, technical, or material support: Ang-Lee, Moss, Yuan.

Study supervision: Moss, Yuan.

Funding/Support: This work was supported in part by the Tang Family Foundation and Clinical Practice Enhancement and Anesthesia Research Foundation.

Acknowledgment: We are indebted to John E. Ellis, MD, and P. Allan Klock, Jr, MD, for their comments on the manuscript and Sally Kozlik for her editorial assistance.