Perioperative bleeding associated with chronic rhodiola rosea use

Dear Editor,

The increasing use of herbal supplements globally raises important concerns for perioperative management.[1] While widely perceived as safe, some, like Rhodiola rosea, can interfere with physiological processes and pharmacological therapies, posing surgical risks.[2] We report a case of excessive perioperative bleeding linked to chronic Rhodiola rosea use, emphasizing the need for structured preoperative screening of herbal supplements.

A 37-year-old female (ASA I) underwent extensive liposuction of the abdomen, back, buttocks, arms, and neck for lipodystrophy. She denied medication or supplement use during preoperative assessment. Initial laboratory tests were normal (hemoglobin 14.7 g/dL, platelets 271,000/μL, and normal coagulation tests). Anesthesia was induced with propofol, fentanyl, and rocuronium and maintained with sevoflurane. Intraoperatively, excessive bleeding prompted compressive measures and temporary procedural interruption. Postoperatively, hemoglobin dropped to 10.2 g/dL, and she was discharged hemodynamically stable.

That evening, she returned to the emergency room with hypotension, tachycardia, and pallor. Blood tests showed hemoglobin 8.0 g/dL, and thromboelastography (TEG) revealed platelet dysfunction (R 3.7 min, K 5.8 min, angle 50.3°, maximum amplitude 46.4 mm). Further questioning uncovered chronic Rhodiola rosea use, discontinued 1 week prior to surgery. Conservative management with fluids and red blood cell transfusion restored stability, and she was discharged in good condition.

Rhodiola rosea contains rosavin and salidroside, compounds known to inhibit CYP2C9 and P-glycoprotein, potentially altering drug metabolism and hemostasis.[3,4] Additionally, recent studies indicate that salidroside exerts antithrombotic effects by inhibiting platelet aggregation via the AKT/GSK3β pathway, impairing primary hemostasis.[4] Despite discontinuation a week before surgery, its lingering effects could have prolonged bleeding risk.[4,5]

Surgical factors as the primary cause of bleeding were unlikely. The procedure was performed by an experienced surgical team using standard hemostatic techniques, with no significant vascular injury or excessive intraoperative bleeding. Hemodynamic stability was initially maintained, but persistent oozing without a clear focal source suggested an underlying coagulopathy rather than a mechanical cause. The absence of a hematoma or arterial bleeding further supports this hypothesis.

This case highlights the importance of thorough preoperative evaluations, particularly regarding herbal supplement use, which is often underreported. The lack of formal guidelines from the American Society of Anesthesiologists on preoperative discontinuation of herbal supplements complicates perioperative risk assessment.[1] Given the increasing prevalence of herbal product use, further research is essential to elucidate their pharmacological effects and perioperative implications.

We advocate for structured preoperative questioning about herbal supplement use and the development of evidence-based guidelines for their management. This case underscores the potential risks of unregulated herbal medications in surgical settings and the impo`rtance of proactive perioperative strategies to prevent avoidable complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.