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PubMed2001

Flumazenil improves cognitive and neuromotor emergence and attenuates shivering after halothane-, enflurane- and isoflurane-based anesthesia.

PURPOSE: To conduct a randomized, placebo-controlled, double-blinded, clinical experiment testing the hypothesis that flumazenil, a benzodiazepine antagonist, may affect recovery from halothane-, enflurane- and isoflurane-based anesthesia. METHOD: Patients who underwent surgery under N(2)O/O(2) plus halothane (n=100), enflurane (n=100) or isoflurane (n=70) anesthesia were administered flumazenil 1 mg or placebo upon emergence from anesthesia, and their postanesthesia vital signs, vigilance, neurological recovery, shivering, amnesia reversal, and general subjective feeling were assessed. RESULTS: A ten-point vigilance score showed better recovery of flumazenil-treated patients compared to those who received placebo (60-min after halothane anesthesia: 9.9 +/- 0.1 vs 9.5 +/- 0.2, P <0.01; after enflurane: 10 +/- 0 vs 9.4 +/- 0.2, P <0.01; after isoflurane: 10.0 +/- 0 vs 9.3 +/- 0.1, P <0.01). Halothane- and enflurane-flumazenil-treated patients (but not isoflurane) reached a better neurological score (2.97 +/- 0.05 or 3 +/- 0) compared to placebo (2.8 +/- 0.4 or 2.6 +/- 0.4, P <0.01), respectively. Reversal of amnesia was superior in the flumazenil group at 60 min and at 24 hr postsurgery, and more flumazenil patients rated recovery as "pleasant". Flumazenil patients shivered less than placebo patients despite their lower core temperature (at 30 min: halothane: 11% vs 28%, P <0.05; enflurane: 11% vs 30%, P <0.05; isoflurane: 17% for both groups). CONCLUSION: Flumazenil improves recovery of high cortical and neuromotor functions following halothane, enflurane and isoflurane anesthesia, reduces shivering and improves the overall quality of emergence, including patients' subjective feeling.

Adult↗
PubMed1982

Thermal and electromyographic correlates of shivering thermogenesis in the pigeon.

1. Electromyographic, thermal and metabolic measurements were made on pigeons subjected to stepwise ambient cooling. Subsequent signal analysis of the EMG-recordings from the pectoral muscle showed that the mean rectified value (Umrv) is the most reliable EMG-based indicator of metabolic heat production (M). 2. The muscle-abdomen temperature difference was linearly related to M, and correlated strongly with Umrv. 3. The long-term and short-term fluctuations of shivering intensity (Umrv) were highly synchronous in the two main muscles, m. pectoralis and m. supracoracoideus. 4. The EMG-signal approached a Gaussian process at high shivering intensities. Evaluation of the changes in EMG median frequency suggested a size-dependent recruitment of motor units for shivering. 5. It is pointed out that Umrv and the integrated value of EMG are interconvertible and that Umrv should be preferred, because it has more physiological relevance.

Animals↗
PubMed1982

The participation of shivering and nonshivering thermogenesis in warm and cold-acclimated rats.

1. Both shivering and nonshivering thermogenesis are ways of increasing oxygen consumption in the rat. The participation of nonshivering thermogenesis after cold acclimation is well established, but there is little evidence of the relative importance of each kind of thermogenesis in acclimated and nonacclimated rats. 2. Oxygen consumption and rectal temperature were measured in warm and cold-acclimated rats exposed both to cold (10 degrees C) and warm (30 degree C) environments. 3. Shivering was blocked by mephenesin (10 mg/100 g body wt) and nonshivering thermogenesis was blocked by propranolol (0.5 mg/100 g body wt). 4. Control animals were injected with saline (0.5 ml/100 g body wt). 5. The results showed that shivering is not effective in maintaining a constant rectal temperature and that nonshivering thermogenesis does not contribute to the increase in oxygen consumption of warm-acclimated rats exposed to cold.

Acclimatization↗
PubMed1991

[Effects of intravenous clonidine on postoperative shivering].

A study was designed to assess the possible effects of intravenous clonidine on postoperative shivering. Fifty patients undergoing spinal fusion under isoflurane anaesthesia were randomly assigned to two groups (n = 25). Patients in one group were given intravenous clonidine (5 micrograms.kg-1 during the first hour, and 0.3 microgram.kg-1.h-1 thereafter) or placebo. Shivering intensity (rated from 0 to 2) and pulmonary artery blood temperature (theta) was recorded every ten minutes for two hours. Haemodynamic and metabolic data were obtained by way of a Swan-Ganz catheter prior to administering the test drug, and then after 1 and 2 hours. On arrival at the recovery room, theta was 36.2 +/- 0.3 degrees C in the clonidine group, and 36.5 +/- 0.2 degrees C in the placebo group. There were no significant differences in shivering between the two groups. Clonidine significantly decreased blood pressure, heart rate, cardiac output and whole body oxygen consumption. The patients in these series were free from any cardiac disease. Further studies are required to assess the possible beneficial effects of clonidine on postoperative oxygen consumption in patients suffering from heart failure.

Adult↗
PubMed1981

Hypoglycaemia, hypothermia and shivering in man.

1. The present experiments were designed to elucidate the reasons for the fall in central body temperature during hypoglycaemia. 2. The first experiment was carried out at a room temperature of 25 degrees C on 11 male subjects. Hypoglycaemia was induced by infusion of insulin. Heat production (calculated from respiratory gas exchange) rose from a baseline of 5.10 +/- 0.13 kJ/min (mean +/- SEM) to a peak of 6.25 +/- 0.21 kJ/min (P less than 0.001), but core temperature fell concurrently by 0.51 +/- 0.08 degrees C and skin temperature fell by 1.1 +/- 0.2 degrees C. The net heat loss was due to peripheral vasodilatation and sweating. 3. To determine the effect of insulin-induced hypoglycaemia on thermoregulation in a cool environment, the experiment was repeated at a room temperature of 18-19 degrees C on five of the subjects who had air blown over them until shivering was sustained. During this time heat production rose to 10.13 +/- 1.67 kJ/min, but core temperature remained constant. Shivering stopped as plasma glucose fell below 2.5 mmol/l during insulin infusion and the subjects said they no longer felt cold. 4. During hypoglycaemia in the cold peripheral vasodilatation and sweating occurred, skin temperature fell by up to 0.8 degrees C and core temperature fell below 35 degrees C, so subjects had to be rewarmed. 5. Recovery of plasma glucose after hypoglycaemia in the cold was impaired at low body temperatures, but shivering was restored within seconds when glucose was given intravenously.

Adult↗
PubMed2002

Postanaesthetic shivering--a new look at tramadol.

We studied whether tramadol administered at the time of wound closure can prevent postanaesthetic shivering. One hundred and fifty patients scheduled for general anaesthesia and surgery were randomly allocated and tramadol was administered intravenously at a dose of 2 mg.kg(-1) in the high-dose group, 1 mg.kg- in the low-dose group and 0.9% saline in the control group. In the high-dose group, 2% of patients had postanaesthetic shivering, compared to 4% in the low-dose group and 48% in the control group (p < 0.001 vs. tramadol groups). There was no delay in tracheal extubation after reversal of neuromuscular blockade. The incidence of adverse side-effects such as sedation and vomiting did not differ statistically and were clinically not significant. This study strongly supports the use of tramadol at wound closure for prevention of postanaesthetic shivering.

Adult↗
PubMed2002

Autonomic auras: left hemispheric predominance of epileptic generators of cold shivers and goose bumps?

PURPOSE: Autonomic seizures in temporal lobe epilepsies associated with "cold shivers and goose bumps" as a principal ictal sign or aura have only rarely been studied. METHODS: Sixteen patients with autonomic auras [cold shivers or cold sweats (n=11), goose bumps (n=4), one patient showed both ictal signs] were analyzed. RESULTS: Lesions were detected in 12 patients. The etiology was heterogeneous [cryptogenic, arteriovenous (AV)-malformation cyst, trauma, hippocampal sclerosis]. Eight patients underwent epilepsy surgery. The localization and lateralization of the focal epileptic activity in the temporal lobes was determined either by magnetic resonance imaging lesions, EEG, ictal signs, or single-photon emission computed tomography imaging. CONCLUSIONS: The patients with temporal lobe epilepsies associated with "cold shivers and/or goose bumps" showed a left hemispheric predominance of the focal abnormality in the temporal lobe.

Adult↗
PubMed1994

Pre-emptive use of the space blanket reduces shivering after general anaesthesia.

We have investigated the role of aluminized metal foil (space blanket, UN 320), used pre-emptively, in post-anaesthetic shivering and patients' subjective perception of cold after general anaesthesia of short duration. Sixty-eight ASA I and II patients undergoing orthopaedic and plastic surgery on the peripheries were allocated randomly to two groups: those in group 1 were wrapped (not less than 60% of body surface area) in the space blanket before induction of anaesthesia. In group 2 patients had standard surgical draping. In all subjects, anaesthesia was induced with fentanyl and propofol, and maintained with nitrous oxide and enflurane in oxygen, after a laryngeal mask airway was positioned. Patients were asked to grade their perception of cold on a visual analogue scale, before induction and on recovery. Skin (dorsum of hand) and core (nasopharyngeal) temperatures were recorded at 15-min intervals. Occurrence of shivering and cold scores were recorded by blinded observers. Groups were similar in age and gender; duration of anaesthesia was also similar (mean 41.6 (SEM 4.8) vs 47.5 (3.3) min, respectively). The incidences of shivering were 15% and 63% in groups 1 and 2, respectively (P < 0.001). Cold scores were 2.4 (0.4) and 5.7 (0.5), respectively (P < 0.001). Skin temperatures increased with increasing duration of anaesthesia in both groups but were greater at 15, 30 and 45 min in group 1 (33.38 (0.25) vs 31.56 (0.31), 34.46 (0.25) vs 32.45 (0.31) and 35.22 (0.36) vs 33.13 (0.34), respectively; P < 0.001 each comparison). Core temperature increased slightly in group 1 and decreased in group 2 (P = 0.11).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1998

Tramadol reduces the sweating, vasoconstriction, and shivering thresholds.

UNLABELLED: The analgesic tramadol inhibits the neuronal reuptake of norepinephrine and 5-hydroxytryptamine, facilitates 5-hydroxytryptamine release, and activates mu-opioid receptors. Each of these actions is likely to influence thermoregulatory control. We therefore tested the hypothesis that tramadol inhibits thermoregulatory control. Eight volunteers were evaluated on four study days, on which they received no drugs, tramadol 125 mg, tramadol 250 mg, and tramadol 250 mg with naloxone, respectively. Skin and core temperatures were gradually increased until sweating was observed and then decreased until vasoconstriction and shivering were detected. The core temperature triggering each response defined its threshold. Tramadol decreased the sweating threshold by -1.03 +/- 0.67 degrees C microgram-1.mL (r2 = 0.90 +/- 0.12). Tramadol also decreased the vasoconstriction threshold by -3.0 +/- 4.0 degrees C microgram-1.mL (r2 = 0.94 +/- 0.98) and the shivering threshold by -4.2 +/- 4.0 degrees C microgram-1.mL(r2 = 0.98 +/- 0.98). The sweating to vasoconstriction interthreshold range nearly doubled from 0.3 +/- 0.4 degree C to 0.7 +/- 0.6 degree C during the administration of large-dose tramadol (P = 0.04). The addition of naloxone only partially reversed the thermoregulatory effects of tramadol. The thermoregulatory effects of tramadol thus most resemble those of midazolam, another drug that slightly decreases the thresholds triggering all three major autonomic thermoregulatory defenses. In this respect, both drugs reduce the "setpoint" rather than produce a generalized impairment of thermoregulatory control. Nonetheless, tramadol nearly doubled the interthreshold range at a concentration near 200 ng/mL. This indicates that tramadol slightly decreases the precision of thermoregulatory control in addition to reducing the setpoint. IMPLICATIONS: The authors evaluated the effects of the analgesic tramadol on the three major thermoregulatory responses: sweating, vasoconstriction, and shivering. Tramadol had only slight thermoregulatory effects. Its use is thus unlikely to provoke hypothermia or to facilitate fever.

Adult↗
PubMed1994

Rate and gender dependence of the sweating, vasoconstriction, and shivering thresholds in humans.

BACKGROUND: The range of core temperatures not triggering thermoregulatory responses ("interthreshold range") remains to be determined in humans. Although the rates at which perioperative core temperatures vary typically range from 0.5 to 2 degrees C/h, the thermoregulatory contribution of different core cooling rates also remains unknown. In addition, sweating in women is triggered at a slightly greater core temperature than in men. However, it is unknown whether the vasoconstriction and shivering thresholds are comparably greater in women, or if women tolerate a larger range of core temperatures without triggering thermoregulatory responses. Accordingly, the authors sought to (1) define the interthreshold range; (2) test the hypothesis that, at a constant skin temperature, the vasoconstriction and shivering thresholds are greater during rapid core cooling than during slowly induced hypothermia; and (3) compare the sweating, vasoconstriction, and shivering thresholds in men and women. METHODS: Eight men and eight women participated. The men participated on 2 separate days; no anesthesia or sedatives were administered. On each day, they were cutaneously warmed until sweating was induced and then were cooled by a central venous infusion of cold fluid. The cooling rates were 0.7 +/- 0.1 degrees C/h on 1 day and 1.7 +/- 0.4 degrees C/h on the other, randomly ordered. Skin temperature was maintained near 36.7 degrees C throughout each trial. The women were studied only once, in the follicular phase of their menstrual cycles, at the greater cooling rate. RESULTS: The interthreshold range was approximately 0.2 degrees C in both men and women, but all thermoregulatory response thresholds were approximately 0.3 degrees C higher in women. All thresholds were virtually identical during slow and fast core cooling. CONCLUSIONS: Our findings confirm the existence of an interthreshold range and document that its magnitude is small. They also demonstrate that the interthreshold range does not differ in men and women, but that women thermoregulate at a significantly higher temperature than do men. Typical clinical rates of core cooling do not alter thermoregulatory responses.

Adult↗
PubMed1991

The effect of prophylactic fentanyl on shivering in elective caesarean section under epidural analgesia.

The aims of this randomised double-blind study were to investigate whether 25 micrograms of fentanyl administered prophylactically by the epidural route would influence the incidence of shivering in parturients who underwent elective Caesarean section under epidural analgesia and whether it would affect the axillary and calf temperatures. There was a 50% reduction (p less than 0.05) in the overall incidence of shivering in patients who received fentanyl and there was some evidence to suggest that low-dose epidural fentanyl might reduce shivering by an influence on thermoregulation.

Adolescent↗
PubMed1992

Six months of shivering in a district general hospital.

Of 2595 patients admitted to a recovery room in Derbyshire Royal Infirmary over a 6-month period, 164 (6.3%) shivered postoperatively. Data regarding the anaesthetic techniques to which these patients had been subjected were gathered from the Derby Anaesthetic Audit System. Subsequent analysis demonstrated the importance of a number of factors that led to shivering, including male gender, anaesthetic techniques involving spontaneous ventilation, and anticholinergic premedication. The administration of pethidine, alfentanil or morphine intra-operatively reduced the incidence of shivering postoperatively.

Adolescent↗
PubMed1994

The intensity of postoperative shivering is unrelated to axillary temperature.

The relationship between axillary temperature and postoperative shivering was examined in 302 patients who entered one recovery room in the Derbyshire Royal Infirmary over a one-month period. No relationship was found between temperature and the occurrence of shivering, or between conscious level and the occurrence of shivering.

Anesthesia Recovery Period↗
PubMed1996

The effect of prophylactic clonidine on postoperative shivering. A large prospective double-blind study.

The primary goal of this study was to assess the influence of clonidine administered after induction on postoperative shivering after elective peripheral surgery. The effect of clonidine on intra-operative haemodynamics (blood pressure and heart rate) during the first 30 min after induction and on the postoperative sedation of the patient was also investigated. Two hundred and eighty male ASA 1 and 2 patients, undergoing elective peripheral surgery were randomly administered either placebo or clonidine 2 micrograms.kg-1 intravenously over 10 min after induction of anaesthesia. Clonidine was found to reduce the total incidence (p = 0.024), the severity (p = 0.005) and the duration (p = 0.01) of postoperative shivering. Clonidine did not increase postoperative sedation or diminish overall consciousness. We conclude that administration of clonidine 2 micrograms.kg-1 intravenously after induction of anaesthesia is safe and reduces postoperative shivering in this group of patients.

Adrenergic alpha-Agonists↗
PubMed2005

Nefopam or clonidine in the pharmacologic prevention of shivering in patients undergoing conscious sedation for interventional neuroradiology.

The aim of this randomised, double-blind study was to investigate the usefulness of intravenous nefopam, clonidine or placebo in preventing shivering in patients undergoing conscious sedation for interventional neuroradiological procedures. A total of 101 patients were prospectively enrolled and assigned to one of three groups to receive nefopam, clonidine or placebo. The overall incidence of intra-operative shivering was significantly lower in patients treated with nefopam than in those treated with clonidine or placebo (2/32 (6%) vs. 11/38 (29%), p < 0.02; 2/32 (6%) vs. 24/31 (77%), p < 0.0001, respectively). The number of patients who required ephedrine infusions to maintain a mean arterial pressure of 100 mm Hg was higher in the clonidine group than in the nefopam and placebo groups (18/38 (47%) vs. 5/32 (17%), p < 0.05; 18/38 (47%) vs. 6/31 (19%), p < 0.05, respectively). We found that both nefopam and clonidine significantly lowered the rate and severity of shivering during interventional neuroradiological procedures. Fewer patients in the nefopam group than in the other two groups required vasoactive drugs.

Adult↗
PubMed2005

Comparison of the effects of intrathecal morphine and pethidine on shivering after Caesarean delivery under combined-spinal epidural anaesthesia.

We performed a prospective, randomised, double blind study to compare the antishivering effect of morphine and pethidine when added to intrathecal hyperbaric bupivacaine during elective Caesarean delivery under combined-spinal epidural anaesthesia. Spinal anaesthesia consisted of either 8-10 mg of 0.5% bupivacaine alone (group B; n = 30) with 0.1 mg morphine (group BM0.1; n = 29), with 0.2 mg morphine (group BM0.2; n = 30), or with 10 mg pethidine (group BPeth10; n = 30). The incidences of shivering were 23.3% (7/30) in group B, 17% (5/29) in group BM0.1, 13.3% (4/30) in group BM0.2 and 3.3% (1/30) in group BPeth10 (p < 0.05). The shivering intensity for each patient was significantly higher in group B than the other groups. In conclusion, intrathecal pethidine added to hyperbaric bupivacaine reduces the incidence and intensity of shivering more than does morphine (0.1 or 0.2 mg).

Adult↗
PubMed1984

Effect of pethidine, fentanyl and morphine on post-operative shivering in man.

One hundred consecutive patients who shivered following general or regional anesthesia and a surgical procedure were randomly treated with 25 mg pethidine, 2.5 mg morphine, 25 micrograms fentanyl or sodium chloride 0.9%, given in equal intravenous volumes over a 15-min period. The effects were evaluated every 5 min after the first injection. There was a spontaneous, time-related disappearance of shivering in the sodium chloride-treated patients. In the pethidine-treated group, shivering disappeared more than twice as fast as in the control group. The difference was highly significant at 15 and 20 min (P less than 0.001) and was unrelated to weight, body temperature or duration of anesthesia. Women responded sooner than men, reaching significance at 10 min (P less than 0.05), while men did so only at 20 min. Morphine or fentanyl had no effect. Nausea and vomiting were minimal and of equal incidence in narcotic- and placebo-treated patients.

Adult↗
PubMed1995

The treatment of postanaesthetic shivering: a double blind comparison between alfentanil and pethidine.

It has been postulated that pethidine may mediate its effects on postanaesthetic shivering (PAS) via kappa-opioid receptors. However, clinical evidence indicates that alfentanil, a pure mu-agonist, may also have beneficial effects on PAS. In order to assess whether opioid effects on PAS are effected via kappa receptors, fifty-one patients were randomised to receive alfentanil 250 micrograms (n = 18), pethidine 25 mg (n = 18) or placebo (n = 15) on a double-blind basis for the treatment of established postanaesthesia shivering (PAS). Both drugs proved significantly better in treating PAS than placebo (P < 0.005). Following treatment, blood pressure fell and oxygen saturation increased in patients in the two treatment groups when compared with the control group (P < 0.05). There was a highly significant incidence of reshivering in the alfentanil treated group (P < 0.005). In conclusion, the high incidence of reshivering indicates that alfentanil is unlikely to supercede pethidine in the treatment of PAS, but its initial success rate implies that pethidine's anti-shivering effect is unlikely to be mediated via kappa-opioid receptors.

Adolescent↗