Postanesthetic Shivering

Epidemiology, Pathophysiology, Prevention and Management

2003/11/26

Chih-Min Liu

Reference

Perioperative Shivering

Physiology and Pharmacology

Anesthesiology 2002; 96: 467-84

Postanesthetic Shivering

Epidemiology, Pathphysiology, and Approaches to Prevention and Management

Drugs 2001; 61 (15): 2193-2205

Clinical Anesthesiology, third edition

Chapter 6: Patient monitors; 117-120

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Clinical Considerations

Hypothermia: < 36 oC O2 consumption x 5; decrease saturation; myocardial ischemia and angina Increased mortality rate Monitoring site:
Tympanic membrane: brain temperature Nasopharyngeal mucosa: core temperature Rectum: slow response in change to core temp Esophagus

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Epidemiology

40-60% after volatile anesthetics Young male adult, rare in elder (age impairs thermoregulatory control) Length of anesthesia or surgery Peri-op rewarming procedure: if not Mild hypothermia

The more serious hypothermia, the higher the probability Less common with propofol; more with halogenated agent, pentothal

Anesthetic used

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Pathophysiology

Consequence of postanesthetic shivering

Discomfort Increased pain IICP, IOP O2 consumption (VO2): more 40 120% Increased minute ventilation Cardiac morbidity

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Pathophysiology

Two types of postanesthetic shivering

Thermoregulated shivering
With cutaneous vasoconstriction, the response of hypothermia Perioperative hypothermia

Non-thermoregulated shivering
Mechanism unknown Postoperative pain related?

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Pathophysiology

Origins of Postanesthetic Shivering

Perioperative hypothermia Postoperative pain Perioperative heat loss Direct effect of certain anesthetics Hypercapnia or respiratory alkalosis The existence of pyogens Hypoxia Early recovery of spinal reflex activity Sympathetic overactivity
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Perioperative hypothermia
37.5 37 36.5 36 35.5 35 34.5 34 33.5 33 32.5 0 1 2 3 4 5 Temp

Phase I: 1st hour

Internal redistribution: from center to peripheral Heat loss: skin, viscera

Steady-state

Phase II: 2-4 hours

Phase III:

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Pathophysiology

Early recovery of spinal reflex activity

Residual effect of anesthetics on the inhibiting control exercised by supraspinal structure Propofol in low concentration may have less effect on certain central structure such as the reticular formation, thus faster recovery of descending inhibiter control

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Temperature-regulating system

Thermosensors

Skin to hypothalamus

Afferent pathway, integration area

Spinal cord Modulate: NRM( serotonin), LS(NE) Integration inputs: PO-AH

Central descending shivering pathway: PH Multiple inputs>common efferent signal Spinal motor neurons, axons

Efferent pathway

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Pathophysiology

Human defenses to hypothermia:

Skin vasomotor activity Nonshivering thermogenesis

Cell metabolic without mechanical work, Neonate

Shivering Sweating

Shivering is the last-resort defense

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Pathophysiology

Shivering
Several types 4-8 Hz., waxing-and-waning pattern

Postanesthetic tremor
Thermoregulatory inhibition abruptly dissipates, thus increasing the shivering threshold toward normal New, near-normal threshold activate shivering

Shivering like activity

Pain in post-op and labor female

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Prevention & Management

Perioperative Hypothermia Prevention

Limiting the effects of internal redistribution

Skin surface rewarming with forced-air warmer for 30 minutes

Reduce heat loss

Radiation from skin surface o Room temperature > 23 C if the op field is large Cover the patient as much as possible

Intravenous fluid rewarming

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Prevention & Management

Passive prevention is not enough Active heat transfer

Cutaneous patch is the most efficient Forced warm air better then Water circulation blankets

1/3 cover of the cutaneous surface is enough Under GA > vasodilatation > heat loss

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Prevention & Management

Physical treatment

Shivering threshold:

skin 20%, core 80% skin 4oC = core 1oC

Raise temp to inhibit postoperative shivering:

Radiation heat system Forced air warmer:

reduce frequency and duration of shivering

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Prevention & Management

Medical treatment
Opiates Tramadol, Ketanserin, Nefopam and Ondensetron 2-Adrenergic Agonists Other drugs

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Opiates

Meperidine

Demoral -opioid receptor Shivering threshold Vasoconstriction Sweating

Pure -receptor agonists Morphine, alfentanyl, fentanyl PO-AH, dorsal raphe nucleus neurons, RMN, LS, and the spinal cord
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Others:

Sites of action

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Meperidine( Demoral)

Sweating Vasoconstriction Shivering threshold

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Tramadol, Ketanserin, Nefopam and Ondensetron

The balance of Norepinephrine and serotonin(5-HT) in the PO-AH controls the body temperature set point 5-HT induce hyperthermia; 2-Adrenergic Agonists (clonidine) reduce core temperature Opposite modulatory inputs from NE and serotonergic neurons shifting the shivering threshold All 4 drugs acts on the serotonin neuromediator Encourage the inhibiting effect of serotonin on OP-AH

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Tramadol, Ketanserin, Nefopam and Ondensetron

Tramadol

Inhibits reuptake of 5-HT, NE, dopamine and facilitate 5-HT release Site of action: Pons Analgesic effect, non-opioid analgesic 1 mg/kg for shivering, reduce threshold by 0.8oC Inhibits reuptake of 5-HT, NE, dopamine and lower normal body temperature Analgesic effect, 0.15mg/kg or 20mg Low efficacy Antihypertensive effect, 5 HT2 antagonist, 10mg

Nefopam

Ketanserin

Ondensetron

Antiemetic, 5 HT3 antagonist, 8mg

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2-Adrenergic Agonists

Clonidine 75g

lower the threshold of cutaneous vasoconstriction and shivering by 0.5oC Bolus & perfusion: At the end of op: 1.5 or 3g/kg Cardiac surgery: 200 to 300g
Central Shivering centre is under inhibiting control of the preoptic anterior hypothalamic region 2-Adrenergic Agonists probably strengthened it

Mechanism:

Dexmedetomidine
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Other drugs

Other drugs

NMDA receptor antagonist:

Ketamine Magnesium sulfate 30mg/kg

Methylphenidate 20mg

Analeptic agent, block reuptake of 5-HT

Central acting cholinesterase inhibitor

Physostigmine 0.04mg/kg

Doxapram 100mg or 1.5mg/kg

Respiratory stimulant, central action on pons

Recovery of the descending inhibitor control of the supraspinal effecting centers

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Conclusion

Hypothermia is associated with shivering and many complications, patient should be kept normothermia Prevention of hypothermia consists of limiting heat loss and active rewarming system Effective treatment of shivering will reduce metabolic heat production and must be accompanied by an effective active heating system. Skin surface rewarming is less efficient then medical treatment with meperidine, tramadol, or, in certain situations, clonidine All antishivering drugs except ketanserin have some analgesic properties in humans, suggested that pain and thermoregulation are tightly connected No single structure or pathway is responsible for the shivering response

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Thanks for your attention

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