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Effects of Prophylactic Ketamine and Pethidine to Control Postanesthetic Shivering: a Comparative Study

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Biomedical Research and Therapy, 5(12):2898-2903 Original Research Effects of prophylactic ketamine and pethidine to control postanesthetic shivering: A comparative study Masoum Khoshfetrat1, Ali Rosom Jalali2, Gholamreza Komeili3, Aliakbar Keykha4;∗ ABSTRACT Background: Shivering is an undesirable complication following general anesthesia and spinal anesthesia, whose early control can reduce postoperative metabolic and respiratory complications. Therefore, this study aims to compare the effects of prophylactic injection of ketamine and pethi- dine on postoperative shivering.Methods: This double-blind clinical trial was performed on 105 patients with short-term orthopedic and ENT surgery. The patients were randomly divided into three groups; 20 minutes before the end of the surgery, 0.4 mg/kg of pethidine was injected to the first group, 0.5 mg/kg of ketamine was injected to the second group, and normal saline was injected to the third group. After the surgery, the tympanic membrane temperature was measured at 0, 10, 20, and 30 minutes. The shivering was also measured by a four-point grading from zero (no shiv- ering) to four (severe shivering). Data were analyzed by one-way ANOVA, Kruskal Wallis, Chi-square 1Doctor of Medicine (MD), Fellow of and Pearson correlation. Results: The mean age of patients was 35.811.45 years in the ketamine Critical Care Medicine (FCCM), group, 34.811.64 years in the normal saline group, and 33.1110.5 years in the pethidine group. Department of Anesthesiology and The one-way ANOVA showed no significant difference in the mean age between the three groups Critical Care, Khatam-Al-Anbiya (P=0.645). The incidence and intensity of shivering were significantly higher in the normal saline Hospital, Zahedan University of Medical Sciences, Zahedan, Iran group than in the ketamine and pethidine groups (p=0.001). However, there was no significant difference in the incidence and the intensity of shivering between the ketamine and thepethidine 2Resident of Anesthesiology and Critical groups (p=0.936). Conclusion: The results showed that the 0.5 mg/kg of ketamine could control Care, Zahedan University of Medical the post-anesthetic shivering. Sciences, Zahedan, Iran Key words: Ketamine, Pethidine, Post-anesthetic Shivering 3Physiology Department, Faculty of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran 8 4PhD. Student of Nursing, Mashhad INTRODUCTION drug to control postanesthetic shivering . Another University of Medical Sciences, Surgery and anesthesia disturb the balance between study introduced the use of pethidine with dexam- Mashhad, Iran the production and loss of body temperature. The ethasone as the more effective method than ketamine 9 Correspondence use of anesthetics and opioids leads to motor and and midazolam . Ketamine controls postanesthetic Aliakbar Keykha, PhD. Student of behavioral inhibition, body movements and conse- shivering by multiple mechanism. Ketamine is a drug Nursing, Mashhad University of Medical quently a decrease in body temperature, which re- binding to N-methyl-d-aspartate (NMDA) receptor, Sciences, Mashhad, Iran sults in shivering 1. The core body temperature de- which is critical at different levels in thermoregula- Email: [email protected] creases from 0.5ºC to 1.5ºC after anesthesia induc- tion. NMDA receptors regulate noradrenergic and History tion. All anesthetic drugs specifically change the serotonergic systems in locus coeruleus 10. Previ- • Received: 20 October 2018 2 • temperature-regulating system . Postoperative shiv- ous studies have shown that ketamine is effective in Accepted: 02 December 2018 11–13 • Published: 25 December 2018 ering, in addition to discomfort and dissatisfaction controlling postanesthetic shivering . Therefore, of the patient, accounts for numerous complications this study was conducted to compare the effects of DOI : such as cardiorespiratory abnormalities, increased prophylactic injection of ketamine, and pethidine on https://doi.org/10.15419/bmrat.v5i12.508 oxygen consumption, subsequent cell hypoxia, and post-anesthetic shivering. increased production of lactic acid and carbon diox- ide. The shivering can also increase return time, pain METHODS perception, and intraocular and intracranial pres- Study Design, Ethical Considerations, Pa- sure 3,4. Previous studies recommended various med- Copyright tients ications such as Meperidine, Ketamine plus Midazo- © Biomedpress. This is an open- The current double-blind clinical trial was approved access article distributed under the lam, Neostigmine and Ketanserin to control and treat 5,6 terms of the Creative Commons post anesthetic shivering . by the Deputy of Research and Technology at Za- Attribution 4.0 International license. Pethidine is one of the most effective drugs to con- hedan University of Medical Sciences, Iran, and per- trol postoperative shivering 7. In more recent stud- mitted by the Ethics Committee of the University. All ies, ketamine has also been reported as an effective enrolled patients in the study signed consents after be- Cite this article : Khoshfetrat M, Jalali A R, Komeili G, Keykha A. Effects of prophylactic ketamine and pethidine to control postanesthetic shivering: A comparative study. Biomed. Res. Ther.; 5(12):2898-2903. 2898 Biomedical Research and Therapy, 5(12):2898-2903 ing fully informed. returned with neostigmine (0.04 mg/kg/IV) and at- ropine (0.02 mg/kg/IV). Sample Size andRandomization After obtaining the necessary criteria, the tracheal The sample size was calculated to be 105 people ac- tube was removed from the patients. The type and cording to previous studies and formula to calculate duration of operation were recorded in information sample size. These patients were divided randomly forms. The patients were transferred to a recovery into three groups of 35 after enrolling in the study ward and oxygen therapy was started with a face mask based on inclusion criteria 14. (7 liters per minute), and the patient’s body was cov- ered with a double layer linen bed sheet. Inclusion and Exclusion Criteria An anesthesiologist, who was unaware of processing The inclusion criteria were Class I and II Ameri- and grouping of the studied patients, assessed the pa- can Society of Anaesthesiology (ASA) including no tients for the shivering. The tympanic membrane history of cardiovascular, respiratory, psychiatric, temperature was recorded at 0, 10, 20 and 30 minutes neuromuscular (myoclonus, Parkinson, Huntington, after entering the recovery room. The shivering was multiple sclerosis, seizure), endocrine disorders (dia- evaluated with a four-point grading system. betes and thyroid disorders), and body temperature In case of obtaining the score of two and over, the ranging from 36.5ºC to 38ºC. In addition, patients shivering was treated with 25 mg/IV of pethidine. with intraoperative blood transfusion were also ex- cluded from the study. Statistical Analysis Data were then compared with SPSS version 22 Interventions software using descriptive statistics and one-way The operating room temperature was adjusted to ◦ ANOVA, Kruskal Wallis, chi-square and Pearson cor- 24 C by air conditioner according to the tropical na- relation. ture of the area. Then, the ear temperature was mea- sured and recorded. RESULTS Next, an angiocath number 18 was fixed in the left In total, the patients were composed of 62% of women antecubital fossa for all patients, followed by nor- and 38% of men. There was no significant difference mal saline infusion (10cc/kg). The monitoring device regarding gender distribution among patients in the (SAADAT, Iran) was used to non-invasively moni- three groups (P=0.176) (Table 2). tor of heart rhythm, arterial oxygen saturation, and The mean age of patients was 35.811.45 years in blood pressure. The oxygen was prescribed with a face the ketamine group, 33.1110.5 years in the pethi- mask for patients (7 liters per minute). The anesthe- dine group, and 34.811.64 years in the normal saline sia was induced with propofol (2 mg/kg/IV), midazo- group. The one-way ANOVA showed no significant lam (2 mg/IV), fentanyl (1 µg/kg/IV) and atracurium difference in the mean age between the three groups (0.5 mg/kg/IV). The intubation was done with a video (P=0.645). laryngoscope. During the operation, the anesthe- The mean duration of surgery was 109.2437.87 min- sia continued with 60% N2O, oxygen and propo- fol (100-200 µg/kg/min) and remifentanil (0.05-0.1 utes in the ketamine group, 105.30 36.97 minutes µg/kg/min). A repeated dose of the atracurium, if in the normal saline group and 106.41 35.94 in the needed (0.1 mg/kg/IV), was performed every 20 min- pethidine group, which was not significantly different utes. All medications were injected and stored at (P=0.975) Table 3. room temperature. The frequency of shivering in the groups receiving ke- Twenty minutes prior to the end of surgery, the first tamine and pethidine was significantly lower than in group was injected with 0.4 mg/kg of pethidine (Iran the normal saline group (p=0.001). Pharmaceutical darou pakhsh Company), the sec- The shivering grade was significantly lower inthe ond group with 0.5 mg/kg of ketamine (Manufac- ketamine and pethidine groups than in the normal ture of Germany ROTEXMEDICA company), and saline group (p=0.001). In the normal saline group, the third group with placebo (normal saline); the vol- 86% of patients had postoperative shivering, of which ume of three syringes reached 3 cc. For blinding, the only 6% were severe that reported in the same group. used drugs
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