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PubMed1995

Comparison of vecuronium and meperidine on the clinical and metabolic effects of shivering after hypothermic cardiopulmonary bypass.

The use of vecuronium and meperidine on the clinical and metabolic effects of shivering in mechanically ventilated patients after hypothermic cardiopulmonary bypass (CPB) was compared. Twenty adult male patients undergoing cardiac surgery were randomized to meperidine, 25 to 75 mg (n = 10), or vecuronium, 0.1 microgram/kg (n = 10), for the treatment of shivering during postoperative rewarming. Vecuronium was continued as an infusion at 1.0 microgram/kg/min for 4 hours. Meperidine abolished shivering in 50% of patients with a 60% recurrence within 2 hours and did not correct acute respiratory acidosis when it occurred. Vecuronium uniformly abolished shivering, corrected acute respiratory acidosis, and improved mixed venous oxygen saturation (20% v 4%), decreased oxygen consumption (-32% v -7%) and decreased end-tidal carbon dioxide (-21% v -5%) significantly more than meperidine (p < 0.005). Meperidine administration caused a significant decline in systolic blood pressure (121.9 +/- 10.6 mmHg to 106.9 +/- 8.5 mmHg, p = < 0.02). The authors conclude that, during rewarming after hypothermic CPB, muscle relaxation with vecuronium reverses both the clinical and metabolic effects of shivering more reliably and effectively than repeated boluses of meperidine, and with greater hemodynamic stability. Control can be maintained by continuous infusion of vecuronium with concomitant sedation for up to 4 hours without prolonging intubation time.

Acidosis, Respiratory↗
PubMed2000

Comparison between pentazocine, pethidine and placebo in the treatment of post-anesthetic shivering.

BACKGROUND: We have compared the effects of pethidine, pentazocine and placebo in the treatment of post-anesthetic shivering. METHODS: Forty-five patients who shivered after routine surgery were allocated randomly to receive normal saline (n=15), pentazocine 7.5 mg (n=15) or pethidine 17.5 mg (n=15). RESULTS: After 10 min, 13 patients had stopped shivering in the pethidine group, which was significantly more than the incidence in the two other groups (placebo=2; pentazocine=4) (P<0.01). Pentazocine was not significantly different from normal saline in affecting shivering. CONCLUSION: We conclude that pentazocine 7.5 mg was not effective in the treatment of post-anesthetic shivering.

Adult↗
PubMed1982

Oligodendrocyte abnormalities in shiverer mouse mutant are determined in primary chimaeras.

There is increasing interest in hereditary dysmyelinating mutant mice such as jimpy, quaking, shiverer and twitcher, as animal models for leukodystrophy in man. These mutants are characterized by severe tremor and tonic convulsions. Shiverer is an autosomal recessive mutant which displays abnormal and poor myelination of the central nervous system and is genetically different from the other dysmyelinating mutants. Despite many reports on the morphological and chemical changes which occur in shiverer mice, the pathogenesis of the abnormal and poor myelin formation is unknown. We have now produced chimaeras by aggregation of eight-cell-stage embryos from wild-type and shiverer mutants. Analysis of the white matter of the chimaera suggests that the oligodendrocyte is responsible for the abnormal and poor myelination in shiverer.

Animals↗
PubMed1998

Influence of cold shivering on fine motor control in the upper limb.

The aim of the investigation was to determine the effects of cold shivering on the accuracy of force output in distal, middle and proximal muscles of the upper limb. Test of hand grip strength, elbow flexion and shoulder flexion (each done at 10% maximal voluntary contraction for 15 s) were done under three conditions: (1) thermoneutral air (27 degrees C), a condition of thermal comfort; (2) cold air (10 degrees C), a condition eliciting an increase in tonic muscle activity; (3) and cold air (10 degrees C) with a cold drink (8 degrees C), a condition that causes visible shivering. The averaged (root mean square) electromyogram (AEMG) and mean power frequency (MPF) were measured from proximal, middle and distal arm muscles during the tests and compared. The control of force output was highly effective at thermoneutral condition for all motor tasks. During the cold air condition, all muscles were tonically active but there was no effect on accuracy of test performance. However, AEMG increased approximately 20% (P < 0.05) with respect to test performance in thermoneutral condition. During the cold air/cold drink condition, all muscles were shivering to a different extend. AEMG during test performance increased 30-150% in comparison to thermoneutral condition (P < 0.05). In this case, hand grip and elbow flexion were not adversely affected (these tests require middle and distal muscles) by cold shivering. However, the accuracy of performance of shoulder flexion was adversely affected. This is consistent with the fact that proximal muscles are more active during cold shivering.

Adult↗
PubMed1997

[Comparative study of pethidine and clonidine for prevention of postoperative shivering. A prospective, randomized, placebo-controlled double-blind study].

OBJECTIVE: Patients with ischaemic heart disease and cardiac failure are endangered by an increase in oxygen consumption caused by postoperative shivering. The purpose of this study was to evaluate if pethidine and clonidine, which are well known for their effectiveness in the treatment of this undesirable side effect, can also prevent postoperative shivering if administered at the end of surgery. In addition it was investigated whether their intraoperative application influences the time of extubation and analgesics demand in the early postoperative period. METHODS: 60 patients (ASA I-II) scheduled for elective microsurgical vertebral disc resection were included in the study. After standardised induction of anaesthesia (5 mg x kg-1 thiopental, 2 micrograms x kg-1 fentanyl, 0.1 mg x kg-1 vecuronium) lungs were ventilated with isoflurane vaporized in 66% N2O and 33% O2. The concentration of the inhalation anaesthetic was adjusted to maintain a surgical plane of anaesthesia without supplementary doses of opioids. Patients were randomly allocated in a double-blind fashion to one of three groups (each n = 20) to receive either pethidine (0.3 mg x kg-1) or clonidine (2 micrograms x kg-1) or 0.9% saline (control) 5 minutes prior to the end of surgery. Heart rate, arterial blood pressure and rectal temperature were measured at defined times, as well as the recovery time between the end of anaesthesia and extubation, incidence of postoperative shivering, and the pain level of the patients with a visual analog scale. The frequency and total demand of analgesics were determined using patient controlled analgesia and recorded for two hours postoperatively. RESULTS: The incidence of postoperative shivering in the clonidine group (5%) was less than in the pethidine group (25%) and significantly less than in the saline group (55%). Heart rate and blood pressure values after the administration of clonidine were lower than after pethidine and significantly lower than after saline. The time between end of surgery and extubation was similar in all groups with an average of 18 minutes. No significant differences among the pain scores and the analgesics demand were noted among any of the groups, including the saline control-group. CONCLUSION: Intraoperative administration of clonidine (2 micrograms x kg-1) is suitable for prevention of postoperative shivering. Despite its sedative effects the recovery time until extubation was not prolonged. 0.3 mg x kg-1 pethidine proved to be less beneficial.

Adjuvants, Anesthesia↗
PubMed1990

Extradurals and shivering: effects of cold and warm extradural saline injections in volunteers.

We tested the hypothesis that cooling the extradural space may provoke shivering, by giving three 80-ml extradural injections of warm (39.8 +/- 1.2 degrees C) or cold (17 +/- 2.2 degrees C) saline to four healthy volunteers, whilst recording central temperature and electromyographic activity from four muscles. The first injection (always cold) did not induce shivering in any of the subjects. The second and third injections, randomly cold or warm, were given after induction of shivering with cold blankets, but had no detectable effects on the intensity of shivering. This suggests that shivering in extradural anaesthesia does not result solely from cooling of the extradural space.

Adult↗
PubMed1994

Anticholinergic premedication influences the incidence of postoperative shivering.

We studied 225 healthy adult patients undergoing ENT, dental or orthopaedic surgery; they were allocated randomly to receive one of three different premedications, all given i.m. 1 h before operation. Group 1 received morphine 0.15 mg kg-1 and metoclopramide 10 mg; group 2 received morphine 0.15 mg kg-1 and glycopyrronium 5 micrograms kg-1; group 3 received morphine 0.15 mg kg-1 and hyoscine 5 micrograms kg-1. Patients who were premedicated with an anticholinergic had a significantly greater incidence and severity of postoperative shivering than those in the metoclopramide group. There was no difference in core temperature between patients who shivered and those who did not, either before or during the shivering episode. Shivering did not cause any clinically significant changes in heart rate, arterial pressure, ventilatory frequency or oxygen saturation. As this effect occurred with both glycopyrronium and hyoscine, it suggests that the mechanism by which postoperative shivering is influenced is peripheral to the central nervous system.

Adolescent↗
PubMed1997

Comparison between alfentanil, pethidine and placebo in the treatment of post-anaesthetic shivering.

We have compared the effects of pethidine, alfentanil and placebo in the treatment of post-anaesthetic shivering. Ninety patients who shivered after routine surgery were allocated randomly to receive normal saline (n = 30), alfentanil 250 micrograms (n = 30) or pethidine 25 mg (n = 30). After 10 min, 26 patients had stopped shivering in the pethidine group which was significantly more than the incidence in the two other groups (placebo = 7; alfentanil = 12) (P < 0.0002). Alfentanil was not significantly different from normal saline in affecting shivering. We conclude that alfentanil 250 micrograms was not effective in the treatment of post-anaesthetic shivering.

Adolescent↗
PubMed1998

I.v. clonidine prevents post-extradural shivering.

We have studied the efficacy of i.v. clonidine to prevent shivering in 100 healthy patients who received extradural block for knee arthroscopy. Patients were randomly allocated to two groups. Just before extradural anaesthesia (0 min = baseline), group I (n = 50) received i.v. clonidine 1 microgram kg-1, group II (n = 50) received a saline bolus. Systolic arterial pressure (SAP), heart rate (HR), oxygen saturation (SpO2), cutaneous temperature and level of sedation, were all recorded at baseline and after 10, 20, 30, 45, 60 min. Shivering was evaluated by a blinded investigator for a period of 90 min and was graded as moderate or severe. Three patients in group I shivered compared with 19 in group II (P < 0.001). Patients with severe shivering were seen only in group II. There were no significant differences between the groups during the study period in SAP, HR, SpO2, cutaneous temperature or level of sedation. We conclude that preventive use of i.v. clonidine 1 microgram kg-1 provides a significant reduction in the incidence of post-extradural shivering without clinically relevant adverse side effects.

Adolescent↗
PubMed2005

Efficacy of prophylactic ketamine in preventing postoperative shivering.

BACKGROUND: Treatment with ketamine and pethidine is effective in postoperative shivering. The aim of this study was to compare the efficacy of low-dose prophylactic ketamine with that of pethidine or placebo in preventing postoperative shivering. METHODS: A prospective randomized double-blind study involved 90 ASA I and II patients undergoing general anaesthesia. Patients were randomly allocated to receive normal saline (Group S, n=30), pethidine 20 mg (Group P, n=30) or ketamine 0.5 mg kg(-1) (Group K, n=30) intravenously 20 min before completion of surgery. The anaesthesia was induced with propofol 2 mg kg(-1), fentanyl 1 microg kg(-1) and vecuronium 0.1 mg kg(-1). It was maintained with sevoflurane 2-4% and nitrous oxide 60% in oxygen. Tympanic temperature was measured immediately after induction of anaesthesia, 30 min after induction and before administration of the study drug. An investigator, blinded to the treatment group, graded postoperative shivering using a four-point scale and postoperative pain using a visual analogue scale (VAS) ranging between 0 and 10. RESULTS: The three groups did not differ significantly regarding patient characteristics. The number of patients shivering on arrival in the recovery room, and at 10 and 20 min after operation were significantly less in Groups P and K than in Group S. The time to first analgesic requirement in Group S was shorter than in either Group K or Group P (P<0.005). There was no difference between the three groups regarding VAS pain scores. CONCLUSION: Prophylactic low-dose ketamine was found to be effective in preventing postoperative shivering.

Adolescent↗
PubMed1995

Alfentanil slightly increases the sweating threshold and markedly reduces the vasoconstriction and shivering thresholds.

BACKGROUND: Hypothermia is common in surgical patients and victims of major trauma; it also results from environmental exposure and drug abuse. In most cases, hypothermia results largely from drug-induced inhibition of normal thermoregulatory control. Although opioids are given to a variety of patients, the thermoregulatory effects of opioids in humans remain unknown. Accordingly, the hypothesis that opioid administration impairs thermoregulatory control was tested. METHODS: Eight volunteers were studied, each on 3 days: (1) a target total plasma alfentanil concentration of 100 ng/ml, (2) control (no drug), and (3) a target alfentanil concentration of 300 ng/ml. Each day, skin and core temperatures were increased sufficiently to provoke sweating. Temperatures subsequently were reduced to elicit peripheral vasoconstriction and shivering. Mathematical compensations were made for changes in skin temperature using the established linear cutaneous contributions to control of sweating (10%) and to vasoconstriction and shivering (20%). From the calculated thresholds (core temperatures triggering responses at a designated skin temperature of 34 degrees C) and unbound plasma alfentanil concentrations, the individual concentration-response relationship was determined. The concentration-response relationship for all the volunteers was determined similarly using total alfentanil concentrations. RESULTS: In terms of unbound concentration, alfentanil increased the sweating threshold (slope = 0.021 +/- 0.016 degrees C.ng-1.ml; r2 = 0.92 +/- 0.06). Alfentanil also significantly decreased the vasoconstriction (slope = -0.075 +/- 0.067 degrees C.ng-1.ml; r2 = 0.92 +/- 0.07) and shivering thresholds (slope = -0.063 +/- -0.037 degrees C.ng-1.ml; r2 = 0.98 +/- 0.04). In terms of total alfentanil concentration (degrees C.ng-1.ml), the sweating threshold increased according to the equation: threshold (degrees C) = 0.0014[alfentanil] + 37.2 (r2 = 0.33). In contrast, alfentanil produced a linear decrease in the core temperature, triggering vasoconstriction: threshold (degrees C) = -0.0049[alfentanil] + 36.7 (r2 = 0.64). Similarly, alfentanil linearly decreased the shivering threshold: threshold (degrees C) = -0.0057[alfentanil] + 35.9 (r2 = 0.70). CONCLUSIONS: The observed pattern of thermoregulatory impairment is similar to that produced by most general anesthetics: a slight increase in the sweating threshold and a substantial, linear decrease in the vasoconstriction and shivering thresholds.

Adult↗
PubMedDate not supplied

Thermal gradients and shivering following open heart surgery.

Critical care nurses caring for postoperative cardiac surgery patients are confronted, on a regular basis, with care issues related to thermal gradients and shivering. Thermal gradients are defined as temperature differences between two body parts. Monitoring the central and peripheral temperatures, evaluating the thermal gradients, and measuring shivering with reliable means are the prerequisites for the prediction of shivering. The detrimental physiologic effect of shivering necessitates additional clinical research to further define causative factors of shivering.

Cardiac Surgical Procedures↗
PubMed2005

Fuel selection in shivering humans.

Heat exchange has been thoroughly studied in cold-exposed humans, but the metabolic substrates used for thermogenesis have received less attention. This review deals with oxidative fuel selection in shivering humans. Lipids provide most of the heat during low-intensity shivering, whereas carbohydrates become dominant under more extreme cold conditions. The contribution from plasma glucose always remains minor, but muscle glycogen plays an important role during intense shivering. Whether the size of muscle glycogen stores influences endurance in the cold remains to be demonstrated. The fuel selection patterns of shivering and exercise are different, but the mechanisms underlying this difference have not been investigated. The simultaneous measurement of metabolic substrate oxidation and muscle fibre recruitment has allowed to characterize two different mechanisms of fuel selection in shivering humans: the recruitment of different pathways within the same fibres and of different fuel-specific fibres within the same muscles. This suggests that muscle fibre composition of each individual may affect survival. Future research promises to provide a combination of theoretical advances on fundamental principles of fuel selection and applied strategies to manipulate fibre composition (through training) or fuel metabolism (through diet) to prolong human survival in cold environments.

Blood Glucose↗
PubMed1994

A comparison of thiopentone and propofol with respect to the incidence of postoperative shivering.

One hundred patients (69 female) undergoing surgical excision of three or more wisdom teeth were randomly allocated to receive either thiopentone or propofol for induction of anaesthesia. Other than the induction agent, the anaesthetic regimen was standardised for all cases. All patients were observed for 15 min after entry into the recovery area to assess the presence and intensity of shivering. Twenty-five patients in the thiopentone group (n = 50) and 11 patients in the propofol group shivered postoperatively (p < 0.005). There was no statistically significant difference in axillary temperature between shivering and non-shivering patients. The use of propofol as an induction agent is associated with a lower incidence of postoperative shivering than thiopentone.

Adult↗
PubMed1996

Postanaesthetic shivering in children.

This study was designed to assess the incidence, severity and possible aetiological factors of postanaesthetic shivering in children. Three hundred and seventy-six children undergoing general anaesthesia were enrolled in the study. Tympanic membrane temperatures were recorded pre-operatively and every 15 min postoperatively in the recovery room until discharge to the ward. Also recorded were all anaesthetic data including fluid administration, methods of temperature preservation used, sedation scores and shivering (using a four-point scale). The overall incidence of shivering was 14.4%. Multiple regression analysis identified three factors that were significantly related to shivering: age, the administration of atropine and peri-operative temperature changes. Children who shivered rewarmed faster in the recovery room.

Adolescent↗
PubMed2004

A comparison of nefopam and clonidine for the prevention of postanaesthetic shivering: a comparative, double-blind and placebo-controlled dose-ranging study.

Postanaesthetic shivering is a frequent complication following general anaesthesia. The aim of this study was to compare the effectiveness of three doses of nefopam with clonidine and placebo in the prevention of postanaesthetic shivering. We studied 371 patients undergoing abdominal or orthopaedic surgery. Patients were allocated to one of five groups: Group A (n = 73) received 0.2 mg x kg(-1) nefopam, Group B (n = 75) 0.1 mg x kg(-1) nefopam, Group C (n = 76) 0.05 mg x kg(-1) nefopam, Group D (n = 73) 1.5 microg x kg(-1) clonidine, and Group E (n = 74) saline 0.9% as placebo. We found a significant reduction in the incidence of shivering in Group A compared to Group C and clonidine as well as to the placebo group. All active treatments reduced the incidence and the severity of shivering compared to placebo. At 5 min postoperatively clonidine-treated patients showed a significant decrease in MAP and a significantly lower Aldrete score compared to all other groups. No haemodynamic or sedative adverse events were observed in the nefopam-treated patients. The results of our study indicate that nefopam (0.2 mg x kg(-1)) is superior to clonidine (1.5 microg x kg(-1)) in the prophylaxis of postanaesthetic shivering and not accompanied by sedative or haemodynamic side-effects.

Adult↗
PubMed1986

Anaesthetic temperature and shivering in epidural anaesthesia.

The mechanism of shivering during epidural analgesia remains unclear. This study investigates the role of the temperature of the local anaesthetic injected extradurally. Forty patients admitted for elective caesarean section under epidural anaesthesia were studied; 20 were given bupivacaine warmed to 37 degrees C (warm group) and 20 were given bupivacaine stored at 4 degrees C (cold group); the occurrence of shivering in both groups was recorded. The overall incidence of shivering was 27.5%; two patients of the warm group and nine patients of the cold group shivered. This difference was statistically significant (P less than 0.03). The results suggest that there are thermosensory mechanisms in the human spinal canal. In our view, epidural anaesthetic solutions should be warmed to body temperature prior to injection to reduce the incidence of shivering.

Adult↗
PubMed1997

Inhibition of shivering increases core temperature afterdrop and attenuates rewarming in hypothermic humans.

During severe hypothermia, shivering is absent. To simulate severe hypothermia, shivering in eight mildly hypothermic subjects was inhibited with meperidine (1.5 mg/kg). Subjects were cooled twice (meperidine and control trials) in 8 degrees C water to a core temperature of 35.9 +/- 0.5 (SD) degrees C, dried, and then placed in sleeping bags. Meperidine caused a 3.2-fold increase in core temperature afterdrop (1.1 +/- 0.6 vs. 0.4 +/- 0.2 degree C), a 4.3-fold increase in afterdrop duration (89.4 +/- 31.4 vs. 20.9 +/- 5.7 min), and a 37% decrease in rewarming rate (1.2 +/- 0.5 vs. 1.9 +/- 0.9 degrees C/h). Meperidine inhibited overt shivering. Oxygen consumption, minute ventilation, and heart rate decreased after meperidine injection but subsequently returned toward preinjection values after 45 min postimmersion. This was likely due to the increased thermoregulatory drive with the greater afterdrop and the short half-life of meperidine. These results demonstrate the effectiveness of shivering heat production in attenuating the postcooling afterdrop of core temperature and potentiating core rewarming. The meperidine protocol may be valuable for comparing the efficacy of various hypothermia rewarming methods in the absence of shivering.

Adult↗