Postanesthetic

Shivering
Epidemiology, Pathophysiology,
Prevention and Management

2003/11/26 Chih-Min Liu 1

 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
 Anesthetic used
 Less common with propofol; more with halogenated agent, pentothal

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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
 Phase I: 1st hour
37
 Internal redistribution:
36.5
from center to peripheral
36

35.5
 Phase II: 2-4 hours
35
 Heat loss: skin, viscera
34.5  Phase III:
34 Temp
 Steady-state
33.5

33

32.5
0 1 2 3 4 5

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

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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%
 Raise temp to inhibit postoperative shivering:
 skin 4oC = core 1oC
 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

 α2-Adrenergic Agonists

 Other drugs

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 Opiates
 Meperidine
 Demoral
 Κ-opioid receptor
 Shivering threshold
 Vasoconstriction
 Sweating
 Others:
 Pure μ-receptor agonists
 Morphine, alfentanyl, fentanyl
 Sites of action
 PO-AH, dorsal raphe nucleus neurons, RMN, LS, and the
spinal cord

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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; α2-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
 Nefopam
 Inhibits reuptake of 5-HT, NE, dopamine and lower normal body temperature
 Analgesic effect, 0.15mg/kg or 20mg
 Ketanserin
 Low efficacy
 Antihypertensive effect, 5 HT2 antagonist, 10mg
 Ondensetron
 Antiemetic, 5 HT3 antagonist, 8mg

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 α2-Adrenergic Agonists
 Clonidine 75μg
 lower the threshold of cutaneous vasoconstriction and
shivering by 0.5oC
 Bolus & perfusion:
 At the end of op: 1.5 or 3μg/kg
 Cardiac surgery: 200 to 300μg
 Mechanism:
 Central
 Shivering centre is under inhibiting control of the preoptic
anterior hypothalamic region
 α2-Adrenergic Agonists probably strengthened it
 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
 Physostigmine 0.04mg/kg
 Central acting cholinesterase inhibitor
 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

2003/11/26 Chih-Min Liu 24