19434-21921939510-3-PB

ACTA BIOCLINICA Volumen 14, N° 27 Enero/Junio 2024
Depósito Legal: PPI201102ME3815

garalanigiro ojab ISSN: 2244-8136
Marjan Chalabi y Col. DOI: https://doi.org/10.53766/AcBio/2023.14.27.03
Investigating and comparing the effect of two different temperatures of
Marcaine on shivering during and after cesarean section
Marjan Chalabi1 , Mohammadali Sheikhi1 , Shekoufeh Behdad1 , Hoessein
Fallahzadeh2
1. Department of Anesthesia, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
2. Research Center of Prevention and Epidemiology of Non-Communicable Disease,
Department Biostatics & Epidemiology, Faculty of Health, Shahid Sadoughi University of
Medical Sciences, Yazd, Iran
CORRESPONDING AUTHOR: Shekoufeh Behdad, MD, Shahid Sadoughi Hospitsl,
Shahid Sadoughi University of Medical Sciences, Yazd, Iran,
EMAIL: behdad90@gmail.com, behdadshekoufeh@gmail.com
ABSTRACT
Background: Shivering is common in cesarean section under neuraxial anesthesia. This
study was designed with the aim of investigating and comparing the effect of two different
temperatures of marcaine (6 and 24 ºC) on shivering during and after cesarean section.
Materials and Methods: In this double-blind clinical trial study, 64 women candidates for
cesarean were randomly divided into two groups (32): the group receiving marcaine with
room temperature (24 ºC) and the group receiving marcaine with refrigerator temperature
(6 ºC). Spinal anesthesia was performed in the sitting position in the space between L4-L5
and using a 25 G needle. The patient was placed in the supine position. The variables,
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garalanigiro ojab Depósito Legal: PPI201102ME3815
Marjan Chalabi y Col ISSN: 2244-8136
shivering, central body temperature, systolic, diastolic and mean arterial blood pressure,
heart rate, level of sensory block, use of pain reliever supplement and nausea and vomiting
after anesthesia were recorded at specific times and compared between two groups. The
obtained data were analyzed using SPSS version 22 software.
Results: There was no statistically significant difference between the two groups in terms
of age distribution and gestational age. Shivering at 30, 45, 60, 75, 90, 105, 120 and 135
minutes after spinal anesthesia was significantly higher in the 6 degree group. In the 6
degree group, grade 3 and 4 tremors at all times, grade 2 at all times except minutes 10, 15,
and 60, and grade 1 at all times except minute 75 had a greater and sometimes equal
frequency compared to the 24 degree group. The average core body temperature was
significantly lower in the 6 degree group at all times. The mean systolic blood pressure at
30 minutes, diastolic blood pressure at 5, 15, and 30 minutes, and mean arterial blood
pressure at 20, 30, and 45 minutes after spinal anesthesia were significantly higher in the 6-
degree group. The two groups had no statistically significant differences in terms of heart
rate variables, level of sensory block, use of pain reliever supplements, and nausea and
vomiting at any time.
Conclusion: According to the results obtained from the present study and similar studies,
marcaine kept at the temperature of the operating room (24 degrees) compared to the
temperature of the refrigerator (6 degrees) effectively reduces shivering during and after
cesarean section.
Key words: Spinal Anesthesia; Chills; Marcaine; Temperature; Cesarean Section
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Investigación y comparación del efecto de dos temperaturas diferentes de
Marcaína sobre los escalofríos durante y después de la cesárea
REUSMEN
Los escalofríos son comunes en la cesárea bajo anestesia neuroaxial. Este estudio fue
diseñado con el objetivo de investigar y comparar el efecto de dos temperaturas diferentes
de marcaína (6 y 24 ºC) sobre los escalofríos durante y después de la cesárea. En este
estudio de ensayo clínico doble ciego, 64 mujeres candidatas a cesárea se dividieron
aleatoriamente en dos grupos (32): el grupo que recibió marcaína a temperatura ambiente
(24 ºC) y el grupo que recibió marcaína a temperatura de refrigerador (6 ºC). ). La
anestesia espinal se realizó en posición sentada en el espacio entre L4-L5 y utilizando una
aguja de 25 G. Se colocó al paciente en decúbito supino. Las variables, escalofríos,
temperatura corporal central, presión arterial sistólica, diastólica y media, frecuencia
cardíaca, nivel de bloqueo sensorial, uso de suplementos analgésicos y náuseas y vómitos
después de la anestesia se registraron en momentos específicos y se compararon entre dos
grupos. Los datos obtenidos se analizaron utilizando el software SPSS versión 22.
No hubo diferencia estadísticamente significativa entre los dos grupos en términos de
distribución de edad y edad gestacional. Los escalofríos a los 30, 45, 60, 75, 90, 105, 120 y
135 minutos después de la anestesia espinal fueron significativamente mayores en el grupo
de 6 grados. En el grupo de 6 grados, los temblores de grado 3 y 4 en todo momento, los de
grado 2 en todo momento excepto en los minutos 10, 15 y 60, y los de grado 1 en todo
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momento excepto en el minuto 75 tuvieron una frecuencia mayor y a veces igual en
comparación con los de 24 grados. grupo. La temperatura corporal central promedio fue
significativamente más baja en el grupo de 6 grados en todo momento. La presión arterial
sistólica media a los 30 minutos, la presión arterial diastólica a los 5, 15 y 30 minutos y la
presión arterial media a los 20, 30 y 45 minutos después de la anestesia espinal fueron
significativamente más altas en el grupo de 6 grados. Los dos grupos no tuvieron
diferencias estadísticamente significativas en cuanto a las variables de frecuencia cardíaca,
nivel de bloqueo sensorial, uso de suplementos analgésicos y náuseas y vómitos en
cualquier momento. De acuerdo con los resultados obtenidos del presente estudio y
estudios similares, la marcaína mantenida a la temperatura del quirófano (24 grados) en
comparación con la temperatura del refrigerador (6 grados) reduce efectivamente los
escalofríos durante y después de la cesárea.
PALABRAS CLAVE: Anestesia Espinal; Escalofríos; Marcaína; Temperatura; Cesárea
general and nouraxial anesthesia. The INTRODUCTION
incidence of shivering after noraxial Shivering are involuntary muscle
anesthesia is mostly 55% (3). Spinal movements and contractions that the
anesthesia is still a widely used procedure patient cannot control and are easily
for cesarean section. Because it provides visible and recognizable, and if untreated,
many advantages such as quick onset, may continue for long minutes or even
high success rate, minimal exposure of hours after the operation (1, 2). Shivering
mother and fetus to drugs and minimal following surgery often occurs after
34
the whole body and plays an important discomfort for the mother (4).
role in regulating body temperature (11). Prevalence of shivering following spinal
Although temperature regulation anesthesia in cesarean section has been
mechanisms can partially explain reported as 40-70% (5, 6). Shivering is
shivering in hypothermic patients. very uncomfortable for the patient and
Different mechanisms, such as the may affect their satisfaction and decisions
function of N-methyl-di-aspartate for regional block in surgeries and
(NMDA) and 5-hydroxytryptamine especially subsequent cesarean sections
receptors, have been proposed to explain (7). Shivering increases oxygen
shivering in normothermic patients (3). consumption, CO2 production, and
Many studies have been conducted to sympathetic tone, and this is
treat shivering after spinal anesthesia. But accompanied by an increase in cardiac
there is little information about the cause output, heart rate, blood pressure, and
of shivering and the best way to prevent it intraocular pressure (8). These effects are
(12, 13). Some studies have shown that particularly annoying in the
the temperature of the injected local gynecological population (9). Controlling
anesthetic drug can contribute to the body's internal temperature depends
shivering after spinal anesthesia (7, 14). on temperature-sensitive neurons that are
The result of another study suggested the located throughout the body inside and
existence of heat-sensing mechanisms in outside the central nervous system(10).
the human spinal canal and the effect of The central nervous system, including the
warming epidural anesthetic solutions spinal cord, receives thermal signals from
35
the group receiving marcaine kept at before injection to reduce the incidence
refrigerator temperature (6 ºC). For all of shivering (15). On the othe hand, some
patients, the same pretreatment studies concluded that shivering in
procedures were performed. Before extradural anesthesia is not alone caused
spinal anesthesia, patients were by the cooling of the extradural space
monitored and received Ringer's solution (16). So, there are conflicting opinions
(5cc/kg). Oxygen was provided during and there is no definitive answer.
anesthesia and the patients had a normal Therefore, this study was designed with
temperature in the range of 37ºC. Patients the aim of investigating and comparing
received a single dose of metoclopramide the effect of marcaine stored at operating
(10 mg) before cesarean section and were room temperature (24 ºC) and refrigerator
randomly divided into two mentined temperature (6 ºC) on shivering during
groups. For prevention of the possible and after cesarean section.
temperature change of Marcaine (6ºC),
the refrigerator was very close to the MATERIALS AND METHODS
operating room. The drug was transferred In this double blind clinical trial study, 64
to the operating room when the CSF women candidates for cesarean surgery
sample was taken, and the syringes of were included in the study. This number
this group were also kept in the was divided into two groups (32 patints
refrigerator. The drugs were prepared by in each group: group 1: the group
the anesthesiologist according to the receiving marcaine kept at operating
existing random chart and given to the room temperature (24 ºC) and group 2:
36
cases where analgesic supplement was anesthesia resident who performed the
needed, Fentanil (1-2 mic/kg) was used spinal block, and therefore the anesthesia
IV. The parameters recorded during the resident was unaware of the temperature
study included: shivering with degrees of the injected marcaine. Spinal
one to four (based on the Crosley and anesthesia was performed in a sitting
Mahajan shivering scale), core body position in the space between L4-L5
temperature (using an OMRON brand using a 25 G Quincke needle and 0.5%
tympanic thermometer), level of sensory marcaine (AstraZeneca Company) at a
block (using the Pinprick test with a blunt speed of approximately 0.2 ml/sec. Then
21G needle at the level of dermatomes the patient was placed in the supine
T4, T5 (near the nipple), T2 and T3 position. After receiving spinal
(above the nipple level) and dermatomes anesthesia, patients are treated with IV
lower than T5 (below the nipple level), ephedrine (5 mg) in case of hypotension
systolic, diastolic, mean arterial blood in the form of >100 mmHg systolic blood
pressure and heart rate (based on pressure or >30% decrease in mean
monitor), the need for pain reliever and arterial pressure from baseline. In cases
nausea and vomiting supplements. The of shivering with intensity ≥3 according
were recorded every five minutes for the to Crosley and Mahajan shivering scale,
first twenty minutes, then every ten they were treated with 25 mg pethidine
minutes until thirty minutes, and finally IV. In case of moderate to severe nausea
every 15 minutes until the end of the and vomiting, metoclopramide was
recovery time. The level of sensory block injected IV at the rate of 10 mg, and in
37
Klomogrove-Smirnov statistical test was was recorded every five minutes for the
used, and descriptive statistics were used first twenty minutes and then every ten
to determine the mean and standard minutes until thirty minutes. Shivering
deviation indicators. P < 0.05 was severity was evaluated according to the
considered statistically significant. specific shivering scale for neuraxial
RESULTS anesthesia defined by Crosley and
Totaly, 64 women candidates for Mahajan (36), as follows: 0: no
caesarean section were included in this shivering, 1: No muscle activity is visible
study and were divided into two groups but there is peripheral vasoconstriction or
receiving marcaine kept at operating flexibility or bot, 2: Muscle activity in
room temperature (24 ºC) and the group only one muscle group, 3: Moderate
receiving marcaine kept at refrigerator muscle activity in more than one muscle
temperature (4 ºC). The two studied group but no general tremor, and 4:
groups were compared in terms of Intense muscle activity that involves the
demographic variables including age and whole body
gestational age (Table 1). Based on this DATA ANALYSIS METHOD
table, the two groups had no statistically The collected data were analyzed with
significant difference in terms of age spss (version 22). To evaluate the
distribution and gestational age. normality of the data distribution, the
Table 1. Comparison of demographic variables (age and gestational age) between the two
38
groups
Variable Groups P value

24ºC 6ºC
Age 23 23/87 3/837
Gestational age 27/68 27/37 3/293
Two groups were compared in terms of sensory block level variables at the mentioned
times after spinal anesthesia (Table 2).
Table 2. Comparison of sensory block level after spinal anesthesia between two groups
Duration after Groups P value
spinal 24ºC 6ºC
anesthesia (min)
5 T4, T5 37 35 0.734
T2, T3 7 9
lower than T5 8 7
33 T4, T5 35 37 0.717
T2, T3 32 33
lower than T5 6 6
35 T4, T5 35 37 0.717
T2, T3 32 33
lower than T5 6 6
33 T4, T5 35 37 0.717
T2, T3 32 33
lower than T5 6 6
23 T4, T5 35 37 0.717
T2, T3 32 33
lower than T5 6 6
39
compared in terms of shivering variable Two groups did not have a statistically
at the mentioned times after spinal significant difference in terms of the level
anesthesia (Table 3). of sensory block in any of the
investigated times. Two groups were
Table 3. Comparison of shivering variable after spinal anesthesia between two study groups
Duration after 24ºC 6ºC P value

spinal anesthesia
(min)
5 No shivering 23 23 1.000
No muscle activity is visible but there is 3 3
peripheral vasoconstriction or flexibility
or both
Muscle activity in only one muscle 3 3
group
Moderate muscle activity in more than 3 3
one muscle group but no general tremor
Intense muscle activity that involves the 3 3
whole body
or both
group
whole body
or both
group
whole body
40
or both
group
whole body
or both
group
Intense muscle activity that involves the 8
whole body
or both
group
whole body
or both
group
whole body
or both
group
whole body
41
or both
group
whole body
or both
group
whole body
333 No shivering 7 0.031
No muscle activity is visible but there is 3
or both
Muscle activity in only one muscle 2
group
Moderate muscle activity in more than 3
Intense muscle activity that involves the 3
whole body
or both
group
whole body
terms of the shivering variable at 30, 45, The results showed that the two groups
60, 75, 90, 105, 120 and 125 minutes had statistically significant differences in
42
except the 75th minute had a greater after spinal anesthesia. In the group
frequency in the group reciaved marcaein reciaved marcaein 6 ºC, shivering was
6 ºC compared to the group reciaved significantly higher than the group
marcaein 24 ºC . The central body reciaved marcaein 24 ºC. Shivering with
temperature was compared with the help grade 3 and 4 in the 6 degree group at all
of a thermometer at the mentioned times times, grade 2 at all times except 10, 15
after spinal anesthesia (Table 4). and 60 minutes, and grade 1 at all times
Table 4. Comparison of central body temperature variable after spinal anesthesia between
two groups
spinal
anesthesia
(min)
5 59/59 59/35 4/410
01 59/68 59/95 4/440
05 59/35 59/91 4/414
01 59/36 59/00 4/444
01 59/80 59/43 4/444
55 59/93 59/44 4/444
01 59/00 50/50 4/444
55 59/91 50/53 4/444
01 59/80 59/41 4/444
015 59/85 59/05 4/444
001 59/64 59/05 4/440
005 59/56 59/85 4/440
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reciaved marcaein 6 ºC significantly Based on this table, the central body
lower than the group reciaved marcaein temperature of the two groups had
24 ºC. The comparison of systolic and statistically significant differences in all
diastolic blood pressure between the two the investigated times. The average
groups is summarized in Tables 5 and 6. central body temperature in the group
Table 5. Comparison of systolic blood pressure variable after spinal anesthesia between two
groups
28
Duration after spinal 24ºC 6ºC P value

anesthesia (min)
5 114/03 149/18 4/050
01 113/06 110/60 4/590
05 101/09 115/50 4/856
01 101/30 113/39 4/000
01 105/09 110/08 4/406
55 100/88 119/50 4/486
01 113/98 116/45 4/595
55 113/53 113/51 4/609
01 101/43 119/35 4/056
015 115/89 116/99 4/506
001 115/50 115/31 4/650
005 113/44 119/66 4/515
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Table 6. Comparison of diastolic blood pressure variable after spinal anesthesia between two
groups
Duration after spinal 24ºC 6ºC P value
anesthesia (min)
5 85/95 90/61 4/405
01 83/95 81/98 4/136
05 89/45 93/54 4/413
01 80/63 95/45 4/134
01 81/60 90/98 4/445
55 88/15 84/61 4/490
01 83/45 88/06 4/388
55 34/56 34/19 4/558
01 30/05 83/14 4/486
015 34/09 83/10 4/009
001 34/93 34/10 4/648
005 30/05 85/94 4/631
46
differences in terms of diastolic blood Based on the results, the two groups had
pressure at 5, 15, and 30 minutes after statistically significant differences in
spinal anesthesia, and the average terms of systolic blood pressure at 30
diastolic blood pressure in the group minutes after spinal anesthesia, and the
reciaved marcaein 6 ºC higher than the average systolic blood pressure in the
group reciaved marcaein 24 ºC. Mean group reciaved marcaein 6 ºC higher than
arterial pressure was also compared the group reciaved marcaein 24 ºC. Two
between two groups (Table 7). groups had statistically significant
Table 7. Comparison of mean arterial pressure variable after spinal anesthesia between the
two groups
Duration after spinal anesthesia 24ºC 6ºC P value
(min)
5 60/36 38/45 4/461
01 68/94 61/50 4/118
05 66/15 65/15 4/010
01 68/66 61/85 4/400
01 69/06 38/85 4/440
55 63/48 60/15 4/405
01 63/00 68/45 4/896
55 66/60 63/88 4/800
01 65/93 69/35 4/186
015 51/54 63/05 4/158
001 65/85 65/94 4/086
005 63/39 54/44 4/198
47
reciaved marcaein 6 ºC higher than the Two groups had statistically significant
group reciaved marcaein 24 ºC. The differences in terms of mean arterial
comparison of heart rate between the two pressure at 20, 30, and 45 minutes after
groups are summarized in Table 8. spinal anesthesia, and the mean mean
arterial blood pressure in the group
Table 8. Comparison of heart rate variable after spinal anesthesia between the two groups
spinal anesthesia
(min)
5 149/63 110/54 4/031
01 149/08 110/09 4/038
05 141/48 140/05 4/610
01 140/51 144/04 4/005
01 55/89 53/98 4/840
55 55/58 50/48 4/560
01 50/94 55/08 4/655
55 66/55 65/36 4/691
01 66/48 63/39 4/505
015 69/95 65/59 4/353
001 68/93 60/94 4/346
005 66/31 54/10 4/631
times. The use of analgesic supplements Two groups did not have a statistically
in patients of both groups at the significant difference in terms of the heart
mentioned times was also investigated, rate variable at any of the examined
28
9. and the results are summarized in Table
Table 9. Comparison of the use of analgesic supplement after spinal anesthesia between two
groups
spinal anesthesia
(min)
5 4 4 1/444
01 4 4 1/444
05 4 4 1/444
01 4 4 1/444
01 4 4 1/444
55 4 4 1/444
01 1 1 1/444
55 1 1 1/444
01 4 1 4/051
015 1 1 1/444
001 4 4 1/444
005 4 4 1/444
compared between the two groups (Table There was no statistically significant
10). Based on the results of table, the two difference between the two groups in
groups had no statistically significant terms of the use of pain reliever
difference in terms of nausea and supplements in the examined times. The
vomiting in the investigated times. variable of nausea and vomiting was also
50
Table 10. Comparison of nausea and vomiting variables after spinal anesthesia between two
groups
spinal anesthesia
(min)
0 4 4 1/444
5 9 3 4/539
01 0 9 4/944
05 1 5 4/548
01 1 0 4/944
01 4 5 4/115
55 1 0 4/944
01 4 4 1/444
55 4 4 1/444
01 4 1 4/051
015 4 1 4/051
001 4 4 1/444
005 4 4 1/444
higher temperature of marcaine led to a DISCUSSION

This study aimed to evaluate and
decrease in the incidence and severity of
compare the effect of marcaine at two
shivering in the studied patients. Ponte et
different temperatures (6 and 24 ºC) on
al. investigated the relationship between
shivering during and after cesarean
anesthetic temperature and shivering in
section in women under spinal anesthesia.
epidural anesthesia. In this study, 40
According to the obtained results, the
elective cesarean patients under epidural
51
The results of this group showed that anesthesia were divided into two groups.
warming the anesthetic agent can reduce Marcaine 37 ºC was used in one group
the incidence of shivering in patients and Marcaine 4 ºC in the other group.
under anesthesia (17). The result of this Two patients in Marcaine 37 ºC and nine
study was also similar to our study. patients Marcaine 37 ºC had shivering.
Workhoven et al. investigated the effect This difference was statistically
of warm intravenous fluids versus room significant. This reserchers stated that
temperature fluids to reduce shivering in there are heat-sensing mechanisms in the
cesarean delivery under epidural human spinal canal and epidural
anesthesia. Of the 44 studied women, 22 anesthetic solutions should be warmed to
received warm fluids and 22 received body temperature before injection to
room temperature fluids. The incidence reduce shivering (16). Although the
shivering in patients received warm and anesthetic injection site was different in
room temperature fluids was 64 and 14%, this study, the result confirmed our study.
respectively (18). In our study, the effect Walmsley et al evaluated 30 patients’
of intrathecal anesthetic was investigated candidates for tubal ligation under
instead of intravenous fluids, but the extradural anesthesia. All patients first
results of both studies were similar. received bupivacaine (4 ºC) and shivering
Temperature sensitivity of the spinal cord was reported in 47%. Eight patients with
has been studied through in vitro considerable shivering were given
experiments with local changes in the warmer marcaine (up to 41°C). The
temperature of the spinal cord. These shivering stopped in 3 of these patients.
52
and third injections were given randomly studies indicated that local changes in the
(hot or cold) after shivering by a cooling temperature of the spinal cord cause
blanket, but there was no specific effect vascular movements and shivering. On
on the severity of shivering. This showed the other hand, invivo experiments on
that shivering in extradural anesthesia is animals have confirmed the existence of
not caused by cooling of the extradural intrinsic temperature-sensitive neurons in
space alone (16). The results of this group the spinal cord (19, 20). Temperature-
were inconsistent with the results of our sensitive neurons in one area of the
study. In the study of this group, saline central nervous system connect to
was used instead of local anesthetic, the temperature-sensitive neurons in other
injection site and temperature of saline areas, forming a temperature-sensitive
were different from our study. The neural network that is hierarchically
difference between the results of our organized in the central nervous system
study and Ponte's group could be due to (21-23). Ponte et al. evaluated the
these differences. Najafi Anarki et al. hypothesis that cooling the extradural
randomly divided 78 candidates for space may induce shivering by giving 3
caesarean section under spinal anesthesia injections of 80 cc of warm or cold saline
into two groups: The warm group to four healthy volunteers in which core
received 2cc of Marcaine (0.5% ) at room temperature and electromyographic
temperature and 10mic of fenanyl, and activity of four muscles were recorded.
the cold group received 2cc marcaine The first injection (always cold) did not
(0.5% ) at refrigerator temperature and cause shivering in any case. The second
53
al. study, we compared the marcaine with 10mic of fentanyl. The incidence of
room (24 ºC) and refrigerator (6ºC) shivering was 8.3% in the warm group
tempraturs. We showed that the shivering and 39.1% in the cold group, which was
was significantly higher in refrigerator significant. In this study, the time for the
marcaine. Regarding other variables, our highest level of sensory block, the highest
study had similar results. In our study, blocked segment, the amount of bleeding,
systolic blood pressure at 30 minutes, heart rate, newborn Apgar, and nausea
diastolic blood pressure at 5, 15, and 30 and vomiting at separate times did not
minutes, and mean arterial pressure at 20, have a significant difference between the
30, and 45 minutes after spinal anesthesia two groups, and the need for an
in refrigerator marcaine was significantly additional dose of analgesic agent was
higher than other group. Shivering causes not observed in any of the groups.
vasoconstriction and high blood pressure Systolic and diastolic blood pressure was
(14), this can justify the higher blood higher in the cold group (14). According
pressure in the refrigerator marcaine. to the drug brochure, marcaine should not
Elsharkawy et al. studied 120 patients be stored at a temperature higher than
(40-70 years old) candidates for 25℃ and freezing of the drug should also
orthopedic surgery under spinal be avoided. Since in some operating
anesthesia. They were randomly divided rooms of hospitals, due to the lack of
into three groups: group 1, received 3 cc proper cooling system, especially in hot
of lobubivacaine (0.5%) with a seasons, marcaine is kept in the
temperature of "24" ℃, group 2, eceived refrigerator. Similar to Najafi Anarki et
54
hypobaric and increases the height of the 3 cc of lobubivacaine (0.5%) with a
block (25, 26). This can justify the temperature of "30" ℃, and group 3,
acceleration of the onset of block in eceived 3 cc of lobubivacaine (0.5%)
groups 30 and 37 in this study, although with a temperature of "37" ℃. The onset
in our study no significant difference in and extent of shivering and the level of
the level of block was observed in the sensory and motor block were measured
investigated time intervals in the two in three groups. These reserchers shoed
groups of marcaine 6 and 24 ºC. that the increasing the temperature of
Mandhari et al. divided 100 patients lobopivacaine up to 30 or 37 ºC led to
(average age of 20-35 years) candidates prolong of the time of onset of shivering
for lower segment cesarean surgery into and the time of the first need for
two groups: Room temperature group, analgesic supplement (24). Despite the
received 2 cc of marcaine 0.5% and 20 difference between this study and our
mic of fentanyl received at a temperature study in terms of age distribution, type of
of "22-23℃", Body temperature group, operation, type of anesthetic and
received 2 cc of 0.5% marcaine and 20 temperature, similar results were obtained
mic of fentanyl at a temperature of regarding the effect of anesthetic
"5.37℃". Shivering was observed in 31 temperature on the degree of shivering.
patients (62%) and 7 patients (14%) in Local anesthetics are isobaric at 24°C but
room temperature and body temperature slightly hypobaric at 37°C. An increase in
groups, respectively. The intensity of temperature, for example, heating the
shivering "≥3" was seen in 15 people anesthetic to body temperature, causes
55
temperature moderately causes spinal (30%) and 5 people (10%) in the room
block sephalic movement, but it is not temperature and body temperature
clear whether this factor or other factors groups, respectively. Warming of
contribute to the subsequent level bupivacaine to body temperature
difference (27). Mandhari et al. showed moderately induces spinal block saphalic
that the warming of bupivacaine to body movement, but it is not clear whether this
temperature caused its more limited or other factors contribute to the
cephalic movement, although the subsequent level difference (35). The
difference was not clinical significant. In results of this study confirmed our study.
our study, there was no significant In our study, shivering in the group
difference in the time intervals at the recieved marcaein 6 ºC were significantly
block level between the two groups. higher than in the group reciaved
Rashid et al (2020) investigated the effect marcaein 24 ºC, and the 3- and 4-degree
of bupivacaine 0.5% and mic20 fentanyl shivering were more frequent and
with two different temprature (37 and 22 sometimes equal compared to the the
ºC) on the incidence of shivering in group reciaved marcaein 24 ºC at all
patients undergoing cesarean section. times. Also, the group reciaved marcaein
This group found that the incidence of 6 ºC had significantly higher systolic,
shivering was 14 and 64% in the groups diastolic and mean arterial blood pressure
37 and 22ºC, respectively. They at several times. While there was no
concluded that the temperature of the significant difference in the rest of the
injected anesthetic agent plays an time. Warming 0.5% bupivacaine to body
56
stored and consumed at the temperature important role in the occurrence of
of the operating room (24 ºC). shivering in patients undergoing cesarean
section (28). The result of this study was
similar to our study. In our study,
marcain with two differebt temperature (6
and 24 ºC) were compared. Data showed
that shivering (grade 1-4) 6-degree group
were significantly higher than the 24-
degree group. Therefore, using marcain
with a higher temperature reduces the
amount and intensity of shivering.
CONCLUSION
Based on the results, marcaine (24 ºC)
effectively reduces shivering during and
after cesarean section compared to the
marcaine (6 ºC). In addition, no side
effects were observed compared to
Marcain at refrigerator temperature.
Therefore, since this drug is stored in the
refrigerator in some centers, it is
recommended that this drug should be
57
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ACTA BIOCLINICA Volumen 14, N° 27 Enero/Junio 2024

Depósito Legal: PPI201102ME3815

Marjan Chalabi y Col. DOI: https://doi.org/10.53766/AcBio/2023.14.27.03

Investigating and comparing the effect of two different temperatures of

Marcaine on shivering during and after cesarean section

Marjan Chalabi1 , Mohammadali Sheikhi1 , Shekoufeh Behdad1 , Hoessein

1. Department of Anesthesia, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

2. Research Center of Prevention and Epidemiology of Non-Communicable Disease,

Department Biostatics & Epidemiology, Faculty of Health, Shahid Sadoughi University of

Medical Sciences, Yazd, Iran

CORRESPONDING AUTHOR: Shekoufeh Behdad, MD, Shahid Sadoughi Hospitsl,

Shahid Sadoughi University of Medical Sciences, Yazd, Iran,

EMAIL: behdad90@gmail.com, behdadshekoufeh@gmail.com

Background: Shivering is common in cesarean section under neuraxial anesthesia. This

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Marjan Chalabi y Col ISSN: 2244-8136

obtained data were analyzed using SPSS version 22 software.

vomiting at any time.

Key words: Spinal Anesthesia; Chills; Marcaine; Temperature; Cesarean Section

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Marjan Chalabi y Col ISSN: 2244-8136

Investigación y comparación del efecto de dos temperaturas diferentes de

Marcaína sobre los escalofríos durante y después de la cesárea

diseñado con el objetivo de investigar y comparar el efecto de dos temperaturas diferentes

de marcaína (6 y 24 ºC) sobre los escalofríos durante y después de la cesárea. En este

estudio de ensayo clínico doble ciego, 64 mujeres candidatas a cesárea se dividieron

(24 ºC) y el grupo que recibió marcaína a temperatura de refrigerador (6 ºC). ). La

aguja de 25 G. Se colocó al paciente en decúbito supino. Las variables, escalofríos,

temperatura corporal central, presión arterial sistólica, diastólica y media, frecuencia

cardíaca, nivel de bloqueo sensorial, uso de suplementos analgésicos y náuseas y vómitos

después de la anestesia se registraron en momentos específicos y se compararon entre dos

No hubo diferencia estadísticamente significativa entre los dos grupos en términos de

135 minutos después de la anestesia espinal fueron significativamente mayores en el grupo

de 6 grados. En el grupo de 6 grados, los temblores de grado 3 y 4 en todo momento, los de

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Marjan Chalabi y Col ISSN: 2244-8136

momento excepto en el minuto 75 tuvieron una frecuencia mayor y a veces igual en

significativamente más baja en el grupo de 6 grados en todo momento. La presión arterial

sistólica media a los 30 minutos, la presión arterial diastólica a los 5, 15 y 30 minutos y la

significativamente más altas en el grupo de 6 grados. Los dos grupos no tuvieron

diferencias estadísticamente significativas en cuanto a las variables de frecuencia cardíaca,

nivel de bloqueo sensorial, uso de suplementos analgésicos y náuseas y vómitos en

estudios similares, la marcaína mantenida a la temperatura del quirófano (24 grados) en

comparación con la temperatura del refrigerador (6 grados) reduce efectivamente los

escalofríos durante y después de la cesárea.

PALABRAS CLAVE: Anestesia Espinal; Escalofríos; Marcaína; Temperatura; Cesárea

general and nouraxial anesthesia. The INTRODUCTION

incidence of shivering after noraxial Shivering are involuntary muscle

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Marjan Chalabi y Col ISSN: 2244-8136

role in regulating body temperature (11). Prevalence of shivering following spinal

Although temperature regulation anesthesia in cesarean section has been

mechanisms can partially explain reported as 40-70% (5, 6). Shivering is

shivering in hypothermic patients. very uncomfortable for the patient and

function of N-methyl-di-aspartate for regional block in surgeries and

(NMDA) and 5-hydroxytryptamine especially subsequent cesarean sections

receptors, have been proposed to explain (7). Shivering increases oxygen

shivering in normothermic patients (3). consumption, CO2 production, and

Many studies have been conducted to sympathetic tone, and this is

treat shivering after spinal anesthesia. But accompanied by an increase in cardiac

the temperature of the injected local gynecological population (9). Controlling

anesthetic drug can contribute to the body's internal temperature depends

existence of heat-sensing mechanisms in outside the central nervous system(10).

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