Severe Hypokalemia and Metabolic Alkalosis Caused by Licorice Discovered During the Treatment of Intraoperative Hypoxemia

Abstract

One of the causes of preoperative hypokalemia is the prolonged use of herbal medicines, especially licorice. Licorice can induce pseudo-aldosteronism, hypertension, metabolic alkalosis, and hypokalemia. An 87-year-old woman with a history of knee osteoarthritis was scheduled to undergo a total knee arthroplasty (TKA) under spinal anesthesia. She had also been prescribed herbal medicine for osteoarthritis of the knee two years before the surgery. During the surgery, the pulse oximeter showed hypoxemia. After the surgery was completed, arterial blood sampling showed hypoxemia, hypokalemia with electrocardiography (ECG) abnormalities, and metabolic alkalosis. The symptoms improved after the discontinuation of herbal medicines and administering potassium chloride. It is necessary to suspect electrolyte abnormalities as one of the causes of hypoxemia, hypertension, or ECG abnormalities in patients prescribed herbal medicines. Therefore, it is also important to ensure that patients on such drugs have their blood potassium levels assessed frequently in the perioperative period.

Case report: Severe respiratory failure caused by licorice

“…The hypothesis that licorice-induced pseudoaldosteronism could underlie diaphragmatic dysfunction holds merit. Although previous reports have suggested a potential link between licorice and respiratory failure (Yasue et al, 2007;Shibata et al, 2022), the lack of a specific report of diaphragmatic dysfunction makes the hypothesis novel. Neither central nervous system abnormality nor pulmonary disease was discovered to elucidate the type 2 respiratory failure of the patient, reinforcing our hypothesis.…”

“…However, licorice can have side effects, including excessive mineralocorticoid activity, which can manifest as sodium retention, hypertension, hypokalemia, metabolic alkalosis, and decreased serum renin and aldosterone activity (Stewart, 2003). The association between licorice and respiratory failure remains relatively unexplored, although several case reports have described this relation (Yasue et al, 2007;Shibata et al, 2022).…”

Torsade de pointes during an oral surgery caused by a combination of herbal medicine-induced pseudoaldosteronism and trigeminocardiac reflex

“…Ultimately, clinically significant hypokalemia developed. There is a report of significant hypokalemia and pseudoaldosteronism manifesting during a surgery, even though non-significant pseudoaldosteronism was previously observed in a patient who consumes licorice [ 4 ]. We can conclude that there are cases where pseudoaldosteronism becomes significant and disastrous during surgery due to perioperative changes, even though the condition was not significant before surgery.…”

Knowledge levels of doctors and nurses working in surgical clinics about nutrients and food supplements, a multicentre descriptive study

“…Nutrients and food supplements alter the efficacy of anticoagulants and antiplatelets [ 28 ], increase the efficacy of antihypertensive and antidiabetic drugs [ 29 ], interact with corticosteroids, central nervous system depressants, opioid analgesics [ 30 ] and anaesthetics [ 31 , 32 ] and increase the efficacy of sedatives and tranquillisers [ 13 ]. These supplements may also cause prolonged sedation [ 31 , 33 , 34 ], delayed recovery from anaesthesia [ 15 , 29 ], bleeding [ 15 , 31 , 33 – 35 ], coagulation disorders [ 34 , 35 ], cardiac problems [ 29 , 34 ], fluid-electrolyte imbalances [ 34 , 36 ], hypoglycaemia [ 15 , 34 ], affecting the need for analgesics after surgery [ 31 ], transplant rejection, irreversible side effects such as kidney [ 29 ] and liver toxicity [ 29 , 37 ] and even death. To prevent complications, side effects, and drug interactions, it is recommended to stop taking nutrients and food supplements two weeks prior to surgery [ 31 , 32 , 35 , 38 – 45 ].…”