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Two independent studies conducted by anesthesiologists are providing some of the first evidence specifically associated with surgical complications and the prolonged use or sudden discontinuation of "alternative" medicines. Often available over the counter, they include herbal remedies, dietary supplements (nutraceuticals), and megavitamins, according to a report to the American Society of Anesthesiologists.

Specialists at M.D. Anderson Cancer Center, Houston, Tex., presented the case of a 37-year-old Chinese man who experienced severe, unexplained internal bleeding near the brain and vocal cords following surgeries to remove a cancerous neck tumor and, later, to restore the use of his vocal cords. A workup by a team of experts revealed that these serious complications could only have been triggered by the patient's long-term consumption of ginseng tea. The patient had not reported his ginseng use before surgery, but his wife mentioned it in passing after the operation. He survived the surgery, but required three additional emergency procedures to manage the severe bleeding.

"We know that ginseng has properties that can interfere with blood clotting, which is why the herb should not be taken with aspirin and other drugs that can affect clotting," points out anesthesiologist Jessie A. Leak. "Now, we have the first case report of serious postsurgical bleeding associated with longtime use of this herb." The incident emphasizes the need for consumers to understand that herbal remedies carry risks. She urges all patients to report their use of these substances in any form (fresh, tablets, teas, vinegar, suppositories, creams, etc.) to anesthesiologists and surgeons before surgery.

Nutraceuticals can have side effects when taken alone or when combined with prescription and over-the-counter (OTC) medicines and anesthesia, cautions Mary Ann Vann, an anesthesiologist and researcher at Beth Israel Deaconess Medical Center, Boston, Mass. A survey of 154 surgical patients revealed that 67% reported using alternative medicines, including vitamins, supplements, and herbal remedies. Vitamins E, C, and B, along with calcium, zinc, glucosamine, and selenium, headed the list of most common vitamins and supplements used.

The most commonly reported herbals included echinacea, garlic, St. John's wort, ginger, and ginkgo. In addition, 19% used herbs and vitamins or supplements; 12% took OTC drugs in addition to herbs, vitamins, and/or supplements; 12% took prescription drugs in addition to herbs, vitamins, and/or supplements; and eight percent reported concurrent use of all four categories of drugs: prescription, OTC, herbs, and vitamins or supplements. Fifty-eight percent reported recent OTC use, and 40% said they took both OTC and prescription drugs.

"The risk of drug interactions is very high while under anesthesia, and the risk of complications rises exponentially with the number of drugs a patient receives," Vann explains. "Given that even routine anesthetic care before, during, and after surgery can involve the administration of many drugs, the use of these additional substances may increase the risk of dangerous interactions."

Of the 79 patients taking alternative medicines, 16% discontinued use of at least one product before surgery, and none began taking any products in preparation for surgery. "We need to identify patients at risk of drug interactions before surgery so changes can be made in these potentially risky drug combinations," she maintains. "We also need to know the hazards of suddenly discontinuing any of these products." For example, the herb St. John's wort, used for mild depression, also decreases the amount of other drugs in the body. The sudden discontinuation of this herb could potentially raise other medications to toxic levels.

Leak highlights eight broad types of potential complications:

Cardiovascular instability. Ephedra, or ma-huang, a cardiovascular stimulant used in thousands of dietary supplements, has been linked with heart attacks, arrhythmia (a potentially serious irregular heartbeat), and chest pain. Considered by Leak to be the most dangerous herbal substance on the market, the herb has been associated with cerebral hemorrhages, strokes, psychosis, and memory loss.

Other herbs and supplements linked with cardiovascular complications include ginseng, used as an energy enhancer; glycyrrhiza glabra (licorice), for stomach problems; and Vitamin E, an antioxidant for cancer and heart disease prevention, in doses greater than 1,200 International Units (IU) daily. St. John's wort, used as a mood enhancer, can decrease levels of the heart medication digoxin by as much as 25%. Patients taking the two substances together could unwittingly jeopardize their cardiovascular health, Leak warns.

Enhanced bleeding potential. Problems with blood clotting can cause major surgical complications. Herbs and supplements believed to affect this process include ginseng; ginkgo biloba, used as a circulatory stimulant or antioxidant; feverfew, to prevent migraine headaches; garlic, to lower blood pressure and quell nausea; and Vitamin E in doses larger than 1,600 IU daily.

Prolonged anesthesia. Kava-kava (piper methysticum), used as a remedy for skin disorders and anxiety, enhances the effects of barbiturates and anti-anxiety drugs (medications commonly used in anesthesia) and produces pain relief similar to a local anesthetic. Valerian and St. John's wort may extend anesthesia's effects as well.

Kidney and liver complications. Echinacea, used to boost the immune system; creatine, a dietary supplement to boost athletic endurance; and licorice may exacerbate existing kidney and liver problems.

Thyroid abnormalities. TRIAC (triiodothyroacetic acid) has been linked with abnormal thyroid function, severe diarrhea, fatigue, lethargy, and profound weight loss.

Electrolyte disturbances. Goldenseal may reduce the effectiveness of high blood pressure medications. Used as a diuretic, the herb is actually an aquaretic that facilitates the excretion of water only, not sodium and water.

Decreased effectiveness of HIV medications. St. John's wort may significantly reduce the effectiveness of protease inhibitors and contribute to the development of resistance to the drugs.

Other side effects of nutraceuticals include postmenopausal bleeding from ginseng; manic episodes with ginseng use by individuals on certain medications for depression; increased risk of suicide in individuals with some kinds of severe depression and kava-kava use; and a greater risk of ulcers with feverfew.