doi:10.1111/jog.14106 J. Obstet. Gynaecol. Res.

2019

Comparison of meperidine, tramadol and fentanyl for

post-spinal shivering prevention during cesarean delivery:
A double-blind randomized controlled trial

Ashokkumar Jayaraj1,2, Hemavathi Balachander3, Suresh K. Kuppusamy4,

Sivakumar Arusamy5, Yeshith Rai6 and Naveed Siddiqui1,2
1
Department of Anesthesia and Pain Management, Mount Sinai Hospital, 6Faculty of Medicine, 2University of Toronto, Toronto,
Ontario, Canada, 3Department of Anesthesia and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and
Research (JIPMER), 4Department of Anesthesia and Critical Care, Manakulavinayagar Medical College and Hospital,
Pondicherry, India, 5Department of Anesthesia and Critical Care, Aster Hospital, Dubai, United Arab Emirates

Abstract
Aim: To assess the effects of intravenously administered meperidine, fentanyl and tramadol in reducing the
incidence, onset time and severity of the shivering response in parturients during cesarean delivery under
spinal anesthesia. Secondary outcomes included patient satisfaction and sedation scores.
Methods: After Ethics board approval and informed written consent, 350 parturients (ASA physical status I
or II), between 20 and 40 years of age, undergoing emergency or elective cesarean delivery under spinal
anesthesia were recruited. Parturients were then randomly allocated to seven study groups: normal saline
(control), low-dose meperidine (0.5 mg/kg), high-dose meperidine (0.75 mg/kg), low-dose fentanyl (0.5
mcg/kg), high-dose fentanyl (0.75 mcg/kg), low-dose tramadol (0.5 mg/kg) and high-dose tramadol
(0.75 mg/kg). The incidence, onset time and severity of shivering, along with patient satisfaction and seda-
tion scores were measured.
Results: All study drugs showed significant reduction in incidence, onset time and severity of shivering and
greater satisfaction scores compared to the control group (P < 0.01). Within each drug class, no significant
differences in shivering were found between the high-dose and low-dose groups. Among study drugs, low-
dose tramadol was superior due to shivering prevention and significantly reduced sedation.
Conclusion: Intravenously administered meperidine, fentanyl and tramadol reduce shivering incidence,
onset time and severity in parturients undergoing cesarean delivery following spinal anesthesia. Impor-
tantly, low-dose intravenous tramadol (0.5 mg/kg) allowed shivering prevention and low sedation scores,
thereby offering greater parturient satisfaction and better maternal–newborn bonding.
Key words: cesarean delivery, fentanyl, meperidine, shivering, spinal anesthesia, tramadol.

Introduction parturient discomfort, it may contribute to increased

intraocular and intracranial pressure, while also inter-
Shivering is a common phenomenon observed in the fering with electrocardiogram monitoring, measure-
operating room in parturients undergoing cesarean ment of pulse oxygen saturation and blood pressure.1–4
delivery following spinal anesthesia. Beyond causing Shivering also has metabolic implications as it has been

Received: June 11 2019.

Accepted: August 14 2019.
Correspondence: Mr Yeshith Rai, Faculty of Medicine, University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada.
Email: yesh.rai@mail.utoronto.ca
Dr Ashokkumar Jayaraj, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Toronto, ON M5G 1X5, Canada.
Email: ashokkumarkarthik1@gmail.com

© 2019 Japan Society of Obstetrics and Gynecology 1

A. Jayaraj et al.
shown to increase metabolic rate, oxygen consumption
and carbon dioxide production, thereby contributing to
arterial hypoxemia and acidosis.2 Length of hospital
stay may also be prolonged as shivering can increase
surgical pain, compromise suture lines, impede wound
healing and ultimately delay discharge from post-
anesthesia care unit.1–4 Post-partum patient satisfaction
scores depend on the presence or absence of shivering5
yet shivering continues to be the most commonly self-
reported problem in cesarean delivery following spinal
anesthesia.6 These wide-ranging factors and associated
complications, necessitate the need for optimal shiver-
ing prevention through perioperative pharmacological
interventions. Previous studies suggest that the use of
intrathecal or epidural mepiridine, tramadol and fenta-
nyl help prevent parturient shivering during cesarean
delivery following regional anesthesia.7–12 However,
apprehension towards placental transfer and neonatal
respiratory depression has prevented intravenous
administration of these agents for shivering control
during cesarean delivery under regional anesthesia.
The primary objective of this study was to compare
the efficacy of intravenous meperidine, tramadol and
fentanyl in reducing the incidence, onset time and
severity of the shivering response in parturients
undergoing cesarean delivery following spinal anes-
thesia. Secondary objectives included the comparison
of patient satisfaction and sedation scores between
the study medications.
Methods
The study was performed at the Jawaharlal Institute of
Postgraduate Medical Education and Research in
Pondicherry, India. At the time of this study, there
were no accounts of average onset time of shivering in
parturients undergoing cesarean delivery following
regional anesthesia. Accordingly, a pilot study was
implemented to establish a baseline shivering onset
time in these parturients. Over a 2-month period,
250 parturients undergoing cesarean delivery following
spinal anesthesia were observed for shivering. The inci-
dence of shivering was found to be 70%, with an aver-
age onset time of 15 min following spinal anesthesia.
Importantly, of the parturients who experienced shiv-
ering, 80% experienced shivering after delivery.
Following approval from the institution’s ethical
committee (SEC/2004/4/50), a prospective, random-
ized, placebo-controlled, double blind study was
implemented. After obtaining informed written consent,
2 © 2019 Japan Society of Obstetrics and Gynecology
350 parturients (ASA physical status I or II), between
the ages of 20 and 40 years, undergoing emergency or
elective cesarean delivery under spinal anesthesia were
recruited to participate in this study. Using the sealed
envelope technique, parturients were randomly allo-
cated to seven study groups: normal saline (control),
low-dose meperidine (0.5 mg/kg), high-dose meperi-
dine (0.75 mg/kg), low-dose fentanyl (0.5 mcg/kg),
high-dose fentanyl (0.75 mcg/kg), low-dose tramadol
(0.5 mg/kg) and high-dose tramadol (0.75 mg/kg).
The doses of the study drugs were well below the rec-
ommended levels for shivering treatment and postop-
erative pain management in cesarean delivery
patients.13–16 Parturients presenting with shivering
before delivery, temperatures greater than 38 C or less
than 36 C, and those with contraindications to spinal
anesthesia and narcotics were excluded from the study.
The attending anesthesiologist who was blinded to the
study drug, administered the appropriate drug
corresponding to the code in the envelope. The parturi-
ent’s name, age, hospital record number, diagnosis and
procedure were written in the same envelope. At the
end of the procedure, the envelope was sealed and
handed over to the investigator. The code was deter-
mined at the end of the study, and the data were
compiled.
Upon completion of the preoperative examination,
intravenous access was established using an 18- or
16-gauge cannula. Ranitidine 50 mg and met-
oclopramide 10 mg were administered intravenously
in the operation theatre. All parturients were informed
about the insertion of a nasopharyngeal probe into the
more patent nostril for continuous monitoring of core
body temperature. Preloading was done using warm
lactated Ringer’s solution at a dose of
10 mL/kg. Parturients continued to receive warmed
intravenous fluids throughout the surgical procedure.
Using standard monitoring, the operating room tem-
perature was maintained at 23 C, with a humidity of
approximately 60%. After preloading, parturients were
placed in the left lateral or seated position and the sub-
arachnoid space was identified using the 26-gauge
Quincke’s spinal needle under aseptic conditions. After
ensuring subarachnoid positioning of the needle – con-
firmed by the free flow of cerebrospinal fluid – 0.5%
bupivacaine was administered in a dose of 7.5–10 mg.
The parturient was then turned to the supine position,
a 10-cm wedge was placed under their right hip and
the level of sensory block was noted. Parturients were
covered with warm drapes while a face mask was used
to administer supplemental oxygen at a rate of
 Cesarean delivery shivering prevention

5 L/min. After delivery, up to 10 units of oxytocin

Grades of shivering were analyzed using a Fischer’s exact test, P-value less than 0.05 is significant.; Occurrence of nausea/vomiting was analyzed using a Fisher’s exact test, P-
The age, weight, baseline temperature and onset of shivering in the various groups were analyzed using one-way analysis of variance test, P-value less than 0.05 is significant.;
(as required) was added to the 500 mL IV fluid drip,

Fentanyl Meperidine Meperidine Tramadol Tramadol F-value P-value P-value (NS vs

test-group)
which was followed by the intravenous administra-

<0.001

<0.001

<0.001
0.62
0.83
0.34
tion of the study drug. The following parameters were
recorded every 5 min for 60 min following delivery;
heart rate, blood pressure, nasopharyngeal tempera-

value less than 0.05 is significant.; †a denotes onset of shivering from the time of administration of the respective drug. and ‡No. denotes the number of patients.
ture, oxygen saturation (SpO2), respiratory rate, grade

0.002

0.029
0.70
0.76
0.59

<0.01
of shivering and grade of sedation. Shivering was
graded using a 4-point scale (0 = no shivering, 1 =
mild fasciculation of face or neck and electrocardiog-

0.633
0.559
0.77

27.19
raphy (ECG) disturbances in the absence of voluntary

51.9

13.7
activity of the arms, 2 = visible tremor involving more
than one muscle group, 3 = gross muscular activities

saline (NS) (low dose) (high dose) (low dose) (high dose) (low dose) (high dose)

65.4  7.5
36.8  0.2

27.8  8.7
24  1.5
involving arms and chest; bed shaking).17 Sedation

1/8/0

17
was evaluated using the Ramsey sedation scale (1 =
anxious, agitated, restless; 2 = cooperated, oriented,
tranquil; 3 = responds to commands only; 4 = brisk

66.3  8.3
36.8  0.1

21.6  6.6
24  2.8
response to light glabellar tap or loud noise; 5 = slug-

1/7/3

8
gish response to light glabellar tap or loud noise; 6 =
no response).18 Shivering (Grade 2 and 3) that
occurred despite the administration of study drugs

23.8  1.6
67.8  8.7
36.8  0.1

33.5  3.8
was controlled by a single dose of meperidine 15 mg

0/4/0

8
intravenously. Parturient satisfaction with shivering
prophylaxis was evaluated and recorded using an
11-point verbal numeric scoring system (0 = not at all
23.7  1.4
67.8  8.0
36.8  0.1

27.5  6.3
satisfied, 10 = fully satisfied). Side effects including

1/5/2
sedation, nausea and vomiting were also recorded.

7
The sample size was calculated to obtain more
than a 20% difference in the occurrence of shivering
between the study groups and placebo, setting the
24.1  1.2
67.2  8.0

16.7  5.5
36.8  01

1/14/4

type 1 error at 0.05 and power of the study at 0.8.

9

Statistical analysis was performed with the Gra-

phPad Prism software (GraphPad Software). Para-
metric data were analyzed using a one-way analysis
23.5  1.7
66.5  8.3
36.8  0.1

13.2  4.5
Fentanyl

6/10/5

of variance, while nonparametric data were analyzed

Table 1 Patients characteristics and adverse effect

using the Kruskal–Wallis test. Category data were

analyzed using the chi-square test. A P-value less
than 0.05 was considered statistically significant.
23.7  1.2
66.6  8.2
36.8  0.2

5.5  1.8

1/12/21
Normal

Data are presented as mean  SD. Grade 3 shivering

3

was used to assess the statistical significance of the

severity of shivering between the groups.
Grades of shivering (No.‡)
Baseline temperature ( C),

Shivering onset (min: a†),

Weight (kg), mean  SD
Age (years), mean  SD

Nausea/vomiting (No.)

Results
All patients who consented to participate completed
mean  SD

mean  SD

the study in their originally assigned treatment

(1/2/3)

group. The study groups were similar in demo-

graphic profile, with no significant differences in the
mean age, weight and baseline temperature
(P > 0.05) (Table 1).

© 2019 Japan Society of Obstetrics and Gynecology 3

A. Jayaraj et al.
Table 2 Occurrence of shivering
Groups Control Count
% within groups
Test Count
% within groups
Total Count
% within groups
Pearson chi-square test is used here to compare the presence of shivering between the control and test groups. The respective chi-square
value and P-values are 39.2 and less than 0.001.
The overall incidence of shivering was 30% across
all study groups. Among the seven groups, the
highest incidence of shivering was observed in the
normal saline (control) group (68%, P < 0.001)
(Table 2). Importantly, a significantly greater number
of parturients from the control group experienced
severe Grade 3 shivering compared to the other
study groups (21/34, P < 0.003) (Table 1). Within
each drug class, no significant differences in inci-
dence and severity of shivering were noted between
the high-dose and low-dose groups (P > 0.1). Among
low-dose groups, both tramadol and meperidine had
comparable results in shivering prevention, reduc-
tion of shivering intensity and threshold (P > 0.05)
(Tables 1–2 and 3). However, low-dose tramadol
was deemed superior for shivering prevention
because it caused significantly less sedation com-
pared to low dose meperidine (P < 0.05) (Table 4).
Low-dose fentanyl was significantly less effective
compared to other study groups (P < 0.03), but still
performed better than the control group in reducing
the incidence and severity of shivering (P < 0.01)
(Tables 1–2). In addition to reducing the incidence
and severity of shivering, all study drugs delayed
the onset of shivering significantly (P < 0.01)
(Table 1) and shivering also occurred at a signifi-
cantly lower temperature compared to the control
group (P < 0.01) (Table 4).
Overall, high-dose study groups had greater – but
not significantly different – sedation scores compared
to low-dose study groups (Table 4). It is worth noting
that none of the patients in any of the study groups
experienced Grade 1, Grade 5 or Grade 6 sedation.
The lowest temperature at which shivering was expe-
rienced by parturients was in the group treated with
high-dose meperidine (35.3 C) (Table 3a and
Table 3b). Incidence of nausea and vomiting was simi-
lar, at approximately 15% across all experimental
groups except in the high-dose tramadol group,
4 © 2019 Japan Society of Obstetrics and Gynecology
Shivering Total
Present Absent
34 16 50
68.0 32.0 100.0
72 228 300
24.0 76.0 100.0
106 244 350
30.3 69.7 100.0
which had a significantly higher occurrence in partu-
rients (17/50, P < 0.05) (Table 1).
Overall parturient satisfaction was significantly
higher in all experimental groups compared to the
placebo (control) group (P < 0.001) (Table 5). When
compared to meperidine and tramadol, fentanyl
showed a significantly lower satisfaction score
(P < 0.05) (Table 5). No significant difference in satis-
faction scores was observed between the high-dose
and low-dose meperidine and tramadol groups
(P > 0.05) (Table 5). Heart rate was maintained
between 60 and 90 beats per minute in all groups
throughout the procedure. SpO2 was maintained
more than 97% and respiratory rate was maintained
above 10 breaths per minute. In all groups, systolic
blood pressure was maintained within 20% from the
baseline values throughout the study period.
Discussion
The results of this study indicate that intravenous
meperidine, tramadol and fentanyl reduce incidence,
onset time and severity of shivering compared to the
saline (control) group. Specifically, low-dose tramadol
(0.5 mg/kg) and low-dose meperidine (0.5 mg/kg)
were most effective in preventing shivering during
cesarean delivery following spinal anesthesia. How-
ever, low-dose tramadol was deemed superior for
shivering prevention because it caused significantly
less sedation compared to other study groups.
The incidence of shivering during spinal anesthesia
was 68% in this study; this finding is similar to the
results reported in previous studies.11,12,19 Pregnancy
is associated with higher vascular sympathetic tone
thus, pharmacological sympathectomy with spinal
anesthesia is more likely to cause profound vasodila-
tation, marked heat loss from the abdomen and lower
limbs. Since shivering in the upper limbs and chest as
 Cesarean delivery shivering prevention

Table 3a Temperature trend in various groups

Groups Baseline Shivering Temperature Temperature Temperature
temperature ( C) threshold ( C) at 30 min at 60 min at 90 min
following spinal following spinal following spinal
anesthesia ( C) anesthesia ( C) anesthesia ( C)
Mean SD Mean SD Mean SD Mean SD Mean SD
Normal saline 36.8 0.2 36.2 0.2 35.9 0.2 35.8 0.23 35.7 0.23
Fentanyl low dose 36.8 0.1 36.0 0.2 35.8 0.1 35.8 0.26 35.7 0.23
Fentanyl high dose 36.8 0.1 35.9 0.2 35.8 0.2 35.7 0.21 35.7 0.21
Meperidine low dose 36.8 0.1 35.7 0.1 35.7 0.25 35.7 0.20 35.7 0.22
Meperidine high dose 36.8 0.1 35.5 0.2 35.5 0.2 35.7 0.27 35.8 0.27
Tramadol low dose 36.8 0.1 35.7 0.1 35.7 0.23 35.7 0.25 35.8 0.24
Tramadol high dose 36.8 0.2 35.6 0.2 35.6 0.2 35.7 0.25 35.8 0.24
Table 3b Temperature trend in various groups

The baseline temperature was analyzed using one-way analysis of variance test, P-value less than 0.05 is significant. Variation of shiver-
ing threshold between the groups was analyzed using a one-way analysis of variance test, P-value less than 0.05 is significant. LSD-Post
Hoc test was used for multiple comparisons between groups.

Table 4 Grades of sedation in different groups

Grades of sedation at 30 mina Grades of sedation at 60 minb
Grade 2 (%) Grade 3 (%) Grade 4 (%) Grade 2 (%) Grade 3 (%) Grade 4 (%)
†
Normal saline (No. = 50) 50 (100.0) 0 (0.0) 0 (0.0) 40 (80) 7 (14) 3 (6)
Fentanyl low dose (No. = 50) 30 (60.0) 16 (32.0) 4 (8.0) 15 (30) 18 (36) 17 (34)
Fentanyl high dose (No. = 50) 12 (24.0) 31 (62.0) 7 (14.0) 10 (21) 22 (44) 18 (36)
Pethidine low dose (No. = 50) 38 (76.0) 10 (20.0) 2 (4.0) 19 (38) 16 (32) 15 (30)
Pethidine high dose (No. = 50) 26 (52.0) 10 (20.0) 14 (28.0) 5 (10) 27 (54) 18 (36)
Tramadol low dose (No. = 50) 39 (78.0) 9 (18.0) 2 (4.0) 38 (76) 8 (17) 4 (8)
Tramadol high dose (No. = 50) 42 (84.0) 8 (16.0) 0 (0.0) 32 (64) 11 (24) 7 (14)
Pearson’s chi square test 109.4 154.2
P-value <0.001 <0.001
For a × b Fisher’s exact test value is equal to 147.8, P-value less than 0.001.; Pearson’s chi-square and Fisher’s exact tests used; P-value less
than 0.05 is significant.; The number of patients developing sedation in the various groups were analyzed by Pearson chi-square and
Fischer’s exact tests. Any difference was considered significant if P-value is less than 0.05.; None of the patients in any of the groups expe-
rienced Grade 1 or Grade 5 or Grade 6 sedation. and †No. denotes number of patients.

© 2019 Japan Society of Obstetrics and Gynecology 5

A. Jayaraj et al.

Table 5 Patient’s satisfaction based on verbal numeric facilitate maternal–newborn bonding within the first
scoring system 30 min following birth. In our study, while both low-
Satisfaction score dose tramadol and low-dose meperidine had similar
Groups Median IQ range Mean SD effects in reducing the incidence and the severity of
Normal saline 3.5 2.0–8.0 4.5 2.7
shivering, low-dose tramadol had decreased sedation;
Fentanyl low dose 7.0 5.0–8.0 6.4 1.8 therefore, low-dose tramadol should be considered as
Fentanyl high dose 8.0 4.0–8.0 6.5 2.1 the treatment of choice for optimal shivering preven-
Meperidine low dose 8.0 8.0–9.0 7.7 1.8 tion and enabling maternal–newborn bonding.
Meperidine high dose 8.0 8.0–9.0 8.1 1.2 Interestingly, there was a recovery of temperature
Tramadol low dose 8.0 8.0–9.0 7.4 2.2
Tramadol high dose 8.0 8.0–9.0 7.5 2.1
near the end of the surgical procedure in the low-dose
Test Kruskal– One-way and high-dose tramadol groups. This recovery could
Wallis analysis analysis of partly be explained by tramadol’s unique mechanism
of variance variance of action; the modulatory effect on central monoamin-
P-value <0.001 <0.001 ergic pathways which inhibit the neuronal uptake of
IQ range denotes inter-quartile range, for example, 50th–75th noradrenaline/serotonin, thereby resetting the body’s
percentile. and P-value less than 0.05 is significant. temperature regulation center.26 While this rise in core
body temperature was also seen in the high-dose
a compensatory mechanism is insufficient to raise or meperidine group, it was not noted in the low- dose
prevent a reduction in core temperature and has sig- meperidine group or any of the fentanyl groups.
nificant adverse sequelae, it should be actively Ondansetron, which was not used in our study, is
prevented in parturients. Moreover, shivering tends routinely used to combat nausea and vomiting in
to be more common, intense and prolonged in the cesarean delivery under spinal anesthesia.27 Since
obstetric population.19,20 ondansetron also has anti-shivering properties,28 future
Pharmacological intervention is thought to be more studies should evaluate using this medication in com-
effective in shivering prevention because non- bination with tramadol to further augment tramadol’s
pharmacological methods such as skin surface anti-shivering properties and reduce the incidence of
warming and warm fluids did not show promising tramadol-induced nausea and vomiting. Moreover,
results in managing perioperative shivering.21,22 intrathecal fentanyl, an agent not used in this study, is
Meperidine is a commonly used medication for shiv- commonly an adjuvant to spinal bupivacaine. Intrathe-
ering prevention. The anti-shivering effects of meperi- cal fentanyl has proven anti-shivering properties dur-
dine may in part be mediated by the activation of ing cesarean delivery under spinal anesthesia11;
kappa-opioid receptors but not the mu-opioid recep- therefore, its use in combination with low-dose
tors since these effects were not reversed by small tramadol may further reduce the incidence of shivering
doses of naloxone.23 Disadvantages of meperidine when combined with tramadol. The findings from this
treatment include the side effects of sedation and respi- study need to be considered in the context of its limita-
ratory depression. Tramadol’s distinct advantage in the tions, namely the lack of consideration for role of
treatment of shivering resides in its weak sedative adjunctive ondansetron in reducing tramadol-induced
property, particularly in parturients.16 In this study, nausea and vomiting and the comparison of anti-
the incidence of somnolence in the group that received shivering properties brought about by intrathecal fen-
low-dose meperidine was significantly more frequent tanyl. Further, the sample used in this study is from a
compared to the low-dose tramadol group (P < 0.05) single region in Pondicherry, India, which may not be
(Table 4). These results corroborate previous findings representative of the general population in India and
by Tsai and Chu.16 Previous studies have shown that across the world, thus potentially limiting the general-
in nonobstetrical populations, the majority of patients izability of these results. Future randomized control tri-
receiving regional anesthesia combined with sedation als with good sample sizes, from more diverse
were satisfied and would choose it again.24 Sedation populations are needed to further investigate these
provides greater comfort to the patient, maintains findings and whether the combination of intrathecal
cardio-respiratory stability, improves surgical condi- fentanyl and intravenous tramadol is more effective in
tions and also provides amnesia during surgery.25 shivering prevention than their use in isolation.
However, following cesarean delivery it is preferable Overall, this study found low-dose tramadol
for the mother to be fully alert and awake in order to (0.5 mg/kg) to be superior to other experimental

6 © 2019 Japan Society of Obstetrics and Gynecology


groups for shivering prevention during cesarean
delivery under spinal anesthesia. Based on the results
of our study, we conclude that adding tramadol at a
dose of 0.5 mg/kg via intravenous route after the
delivery of the baby provides greater parturient satis-
faction and excellent maternal–newborn bonding by
preventing the shivering associated with cesarean
delivery following spinal anesthesia.
Acknowledgments
Authors thank Dr Prasad Senthamizh and Dr Kiruba
Shankar for statistical analysis.
Disclosure
This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-
profit sectors. The authors report no conflict of interest.
References
1. Kranke P, Eberhart LH, Roewer N, Trame MR. Pharmaco-
logical treatment of postoperative shivering. Anesth Analg
2002; 94: 453–460.
2. Bhatnagar S, Saxena A, Kannan TR, Punj J, Panigrahi M,
Mishra S. Tramadol for postoperative shivering: A double-
blind comparison with pethidine. Anaesth Intensive Care
2001; 29: 149–154.
3. Sessler DI. Temperature monitoring and perioperative ther-
moregulation. Anesthesiology 2008; 109: 318–338.
4. Katyal S, Tewari A, Shivering ND. Anaesthetic consider-
ations. J Anaesthesiol Clin Pharmacol 2002; 18: 363–376.
5. Kouki P, Matsota P, Christodoulaki K et al. Greek surgical
patients’ satisfaction related to perioperative anesthetic ser-
vices in an academic institute. Patient Prefer Adherence 2012;
6: 569–578.
6. Hemanth Kumar V, Jahagirdar SM, Athiraman UK,
Sripriya R, Parthasarathy S, Ravishankar M. Study of patient
satisfaction and self-expressed problems after emergency
cesarean delivery under subarachnoid block. Indian J Anaesth
2014; 58: 149–153.
7. Chen JC, Hsu SW, Hu LH et al. Intrathecal meperidine atten-
uates shivering induced by spinal anesthesia. Ma Zui Xue Za
Zhi 1993; 31: 19–24.
8. Roy J-D, Girard M, Drolet P. Intrathecal meperidine
decreases shivering during cesarean delivery under spinal
anesthesia. Anesth Analg 2004; 98: 230–234.
9. Khan ZH, Zanjani AP, Makarem J, Samadi S. Antishivering
effects of two different doses of intrathecal meperidine in
cesarean section: A prospective randomised blinded study.
Eur J Anaesthesiol 2011; 28: 202–206.
10. Subedi A, Biswas BK, Tripathi M, Bhattarai BK, Pokharel K.
Analgesic effects of intrathecal tramadol in patients
© 2019 Japan Society of Obstetrics and Gynecology
Cesarean delivery shivering prevention
undergoing cesarean section: A randomised, double-blind
study. Int J Obstet Anesth 2013; 22: 316–321.
11. Sadegh A, Tazeh-Kand NF, Eslami B. Intrathecal fentanyl
for prevention of shivering in spinal anesthesia in cesarean
section. Med J Islam Repub Iran 2012; 26: 85–89.
12. Liu WH, Luxton MC. The effect of prophylactic fentanyl on
shivering in elective cesarean section under epidural analge-
sia. Anaesthesia 1991; 46: 344–348.
13. Mitra S, Khandelwal P, Sehgal A. Diclofenac–tramadol
vs. diclofenac–acetaminophen combinations for pain relief after
cesarean section. Acta Anaesthesiol Scand 2012; 56: 706–711.
14. Sharma SK, Alexander JM, Messick G et al. Cesarean deliv-
ery: A randomized trial of epidural analgesia versus intrave-
nous meperidine analgesia during labor in nulliparous
women. Anesthesiology 2002; 96: 546–551.
15. Shoorab NJ, Zagami SE, Mirzakhani K, Mazlom SR. The effect
of intravenous fentanyl on pain and duration of the active
phase of first stage labor. Oman Med J 2013; 28: 306–310.
16. Tsai YC, Chu KS. A comparison of tramadol, amitriptyline,
and meperidine for postepidural anesthetic shivering in par-
turients. Anesth Analg 2001; 93: 1288–1292.
17. Mathews S, Al Mulla A, Varghese PK, Radim K, Mumtaz S.
Postanaesthetic shivering – A new look at tramadol. Anaes-
thesia 2002; 57: 394–398.
18. Ramsay MA, Savege TM, Simpson BR, Goodwin R. Con-
trolled sedation with alphaxalone–alphadolone. Br Med J
1974; 2: 656–659.
19. Crowley LJ, Buggy DJ. Shivering and neuraxial anesthesia.
Reg Anesth Pain Med 2008; 33: 241–252.
20. Chan AM, Ng KF, Tong EW, Jan GS. Control of shivering
under regional anesthesia in obstetric patients with
tramadol. Can J Anaesth 1999; 46: 253–258.
21. Butwick AJ, Lipman SS, Carvalho B. Intraoperative forced
air-warming during cesarean delivery under spinal anesthe-
sia does not prevent maternal hypothermia. Anesth Analg
2007; 105: 1413–1419.
22. Goyal P, Kundra S, Sharma S, Grewal A, Kaul T, Singh M.
Efficacy of intravenous fluid warming for maintenance of
core temperature during lower segment cesarean
section under spinal anesthesia. J Obstet Anaesth Crit Care
2011; 1: 73–77.
23. Kurz M, Belani KG, Sessler DI et al. Naloxone, meperidine,
and shivering. Anesthesiology 1993; 79: 1193–1201.
24. Hohener D, Blumenthal S, Borgeat A. Sedation and regional
anaesthesia in the adult patient. Br J Anaesth 2008; 100: 8–16.
25. Mittal G, Gupta K, Katyal S, Kaushal S. Randomised
double-blind comparative study of dexmedetomidine and
tramadol for post-spinal anaesthesia shivering. Indian J Ana-
esth 2014; 58: 257–262.
26. de Witte J, Deloof T, de Veylder J, Housmans PR. Tramadol
in the treatment of postanesthetic shivering. Acta Anaesthesiol
Scand 1997; 41: 506–510.
27. Abouleish EI, Rashid S, Haque S, Giezentanner A,
Joynton P, Chuang AZ. Ondansetron versus placebo for the
control of nausea and vomiting during cesarean
section under spinal anaesthesia. Anaesthesia 1999; 54:
479–482.
28. Kelsaka E, Baris S, Karakaya D, Sarihasan B. Comparison of
ondansetron and meperidine for prevention of shivering in
patients undergoing spinal anesthesia. Reg Anesth Pain Med
2006; 31: 40–45.
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