American Society of Regional Anesthesia and Pain Medicine August 2016 - 37
Herbal Hematomas - Fact or Fantasy?
A
lthough epidural
hematomas can occur
spontaneously, the
introduction of a needle into
the epidural space of an
anticoagulated patient poses
an obvious increased risk
for development of epidural
hematoma. Anticoagulation is
therefore an immediate concern
for anesthesiologists practicing
interventional procedures.
Anna Woodbury, MD, LAc
There has been a great deal
Assistant Professor, Anesthesiology
of effort expended by our
Associate Program Director, Pain
profession to create detailed
Medicine Fellowship
guidelines for anticoagulation
Emory University School of Medicine
in regional anesthesia and
Division Chief, Pain Medicine
interventional pain procedures.
Veterans Affairs Medical Center
Most recent guidelines classify
Atlanta, GA
pain interventions into low-,
intermediate-, and highSection Editor: Magdalena Anitescu, MD
risk procedures and further
define precise timelines for
discontinuation and reinitiation of each anticoagulant or antiplatelet
medication. However, even with the publication of the 2015
multidisciplinary guidelines by Narouze et al,1 the impact of herbs
and supplements on regional anesthesia and interventional pain
procedures remains a relative
black box.
function and warfarin-like effects.1 Six agents were identified as
the most likely culprits for increased bleeding risk: danshen (Salvia
miltiorrhiza), dong quai (Angelica sinensis), garlic (Allium sativum),
Ginkgo biloba, "Asian" or "Korean red" ginseng (Panax ginseng C.A.
Meyer) and "American" ginseng (Panax quinquefolius L.). These
agents and their recommendations are well-summarized within the
guidelines and condensed here:1
1. Routinely inquire about herbal/supplement use and dosages.
2. Discontinue herbal agents and supplements prior to high-risk
elective procedures (7 days for garlic, 36 hours for gingko; 7
days is enough to resume normal hemostasis after stopping
most herbs).
3. Be cautious with low- and medium-risk procedures if the
patient has other bleeding abnormalities or is on other potential
blood-thinning agents.
4. Test platelet function for patients on gingko or on > 1000 mg
per day of garlic (note: 1 tablespoon is approximately 10 000
mg) in conjunction with nonsteroidal antiinflammatory drugs or
selective serotonin reuptake inhibitors.
5. Check international normalized ratio (INR) in patients on dong
quai or danshen with warfarin.
While these guidelines provide some general direction as well
as specifics regarding six key herbs, there are other notable
supplements that also result in blood-thinning effects. It would
be worthwhile, for example, to more closely examine the most
commonly used herbs and
supplements found on
the 2012 National Health
Interview Survey (Table 1).
"Based on the National Health
Interview Survey (NHIS) of 2012,
approximately 33% of adults and 11%
of children in the U.S. reported using a
complementary or alternative therapy
within the previous year"
Based on the 2012 National
Health Interview Survey (NHIS),
approximately 33% of adults
and 11% of children in the
United States reported using a
complementary or alternative
therapy within the previous year,
and these numbers are largely
unchanged from the 2007 NHIS.2
On the same 2012 survey,
approximately 18% of adults in the United States reported using
herbal or nutritional supplementation, with the most commonly
used products being fish oil/omega-3 fatty acids, glucosamine and/
or chondroitin, probiotics/prebiotics, melatonin, and coenzyme Q10
(in descending order). Garlic supplements, ginseng, and gingko
biloba also made it into the top 10 in terms of adult usage in the
United States. There is therefore a pressing need for physicians and
patients to be aware of the risks and benefits associated with use
of these supplements and their effects on conventional therapies.
Current peri-procedural guidelines by Narouze et al do note that
natural compounds can have significant ramifications on platelet
There seems to be a
misperception that
discontinuing herbal and
nutritional supplements
is harmless.3,4 It can be
argued that just as some
patients are dependent on
aspirin to prevent thrombotic
events, others may be unknowingly dependent on garlic or other
supplements to prevent thrombosis. Thus, discontinuation of a
supplement could potentially place a patient at increased risk
of a heart attack, stroke, or other thromboembolic events. This
is, of course, theoretical and would be quite hard to prove even
if an association between an adverse outcome and supplement
discontinuation was suspected.
Further discussion and risk stratification may need to take
place before a decision is made to uniformly discontinue all
herbal supplements prior to a procedure. There are relatively
few case reports of spinal epidural hematoma formation with
American Society of Regional Anesthesia and Pain Medicine
2016
37
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