How Are Nutritional Supplements Rated Articles & Resources

Three months later, Mr. Chang returned for another lesion excision. This time, the procedure went well, with no excessive bleeding. Mr. Chang told me that he'd stopped taking vitamin E and garlic supplements.

Because the change was so dramatic, I decided to investigate what effects vitamins and herbal supplements might have on surgical patients. What I discovered has completely changed the way I perform preoperative patient assessments.

WHAT YOU CAN DO

Dietary supplements can have a significant effect on your patient's response to surgery, yet this information may not appear in a patient's chart. So it's up to you to ask him. If you discover that he's taking a vitamin or dietary supplement, inform his surgeon and counsel your patient on continuing or discontinuing the supplement before surgery.

Here are some popular nutritional supplements and how they may affect surgical patients.

GARLIC

Garlic supplements are increasingly popular among consumers, who may use them to lower cholesterol or treat infections. However, research has shown that garlic decreases platelet aggregation and increases fibrinolytic activity, clotting time, and streptokinase-activated plasminogen activator. It also decreases plasma viscosity.

Although garlic may reduce the risk of thrombotic cardiovascular disease, its potential to increase surgical bleeding is undesirable. Postoperative bleeding is magnified when garlic is combined with any other antiplatelet agents, such as aspirin or nonsteroidal anti-inflammatory drugs.

During your initial assessment, ask your patient if he's taking any form of garlic supplement or eating foods high in garlic. Because researchers haven't determined how long garlic's effects last, ask your patient to stop taking garlic at least 1 week before his scheduled surgery.

VITAMIN E

For both men and women, vitamin E has been widely reported as an agent against cardiovascular disease. Less widely reported, however, is its potential hazard to surgical patients.

Here's what we know about vitamin E:

Vitamin E slows wound healing by impairing collagen synthesis, so patients undergoing tendon or abdominal wall repairs are at particular risk. Vitamin E reduces platelet adhesion at doses of 200 to 400 international units a day. In patients with abnormal platelets (such as those with diabetes and those on renal dialysis), vitamin E decreases platelet aggregation.

When vitamin E is taken with other antiplatelet agents, including aspirin, garlic, and arachidonic acid inhibitors, platelet aggregation is significantly reduced.

Before your patient's scheduled surgery, tell him to stop taking vitamin E. After he recovers and is no longer at risk for bleeding, tell him that he may resume taking the vitamin.

EICOSAPENTAENOIC ACID AND DOCOSAHEXAENOIC ACID (FISH OIL)

These two components in fish oil have been shown to significantly reduce the risk of cardiovascular disease. Additionally, studies have

shown that fish oil:

decreases platelet aggregation and adhesion

increases bleeding time

decreases thromboxane production.

Although these effects may be beneficial in preventing thrombotic cardiovascular events, they're undesirable during invasive procedures, so ask your patient to stop ingesting fish oil before his surgery.

VITAMIN A

In contrast to the substances just discussed, vitamin A offers benefits to surgical patients. Research shows that vitamin A:

combats the inhibition of wound healing by steroid treatments partially reverses immune system depression occurring after surgery, injury, or sepsis

significantly improves a patient's immunologic status after major surgery.

Tell your patient that he should talk with his physician about vitamin A as a perioperative supplement if the patient is taking steroids. However, if the steroid's anti-inflammatory effect is essential (for example, to treat rheumatoid arthritis), you must be careful because the vitamin will eliminate this benefit.

Patients with sepsis and those who are immune-depleted (such as malnourished or elderly patients, those with gastrointestinal dysfunction, and victims of major trauma) should receive vitamin A preoperatively and postoperatively. The dose recommended in one study is 25,000 international units/day; this can be increased with close monitoring.

Vitamin A is contraindicated for pregnant women because it's rated pregnancy "category C," which means safety data are available for its use in pregnant women and the substance has been shown to cause damage to the fetus in animal studies. After consulting their physicians, women who become pregnant should use vitamin A cautiously and for only short periods of time.

BROMELAIN

Bromelain is found in pineapples, especially in the stem. It acts as an anti-inflammatory agent and as a digestive aid. It's also been used topically as a burn-debriding agent. In one study, researchers found that bromelain speeded hematoma resorption in surgical patients.

Patients should receive a dose of 500 mg as soon as possible after surgery and take further doses on an empty stomach four times a day until the hematoma or swelling has resolved.

VITAMIN C

This vitamin is essential to normal wound healing because of its ability to stimulate the immune system. Because surgery decreases the levels of vitamin C in the blood and tissues, vitamin C supplements may be necessary perioperatively. A dose of 1 to 2 grams of vitamin C before and after surgery has been shown to be safe and well tolerated by patients. When your patient's healing is complete and he's eating a normal diet, he can reduce his vitamin C intake over several days to his original intake of the vitamin. The recommended daily allowance is currently 60 mg.

KNOWLEDGE SUPPLEMENT

By learning about nutritional supplements and how they affect your surgical patient, you can head off potential problems-and maybe even speed his recovery

From "Nutritional Supplements and Surgical Patients," by Judith J. Petry, mUD, FACS, in AORN Journal. June 1997, AORN, Inc., Denver, Colo. Adapted with permission of the publisher