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Postanaesthetic Shivering Romanian Journal of Anaesthesia and Intensive Care 2018 Vol 25 No 1, 73-81 REVIEW ARTICLE DOI Postanaesthetic shivering Romanian Journal of Anaesthesia and Intensive Care 2018 Vol 25 No 1, 73-81 REVIEW ARTICLE DOI: http://dx.doi.org/10.21454/rjaic.7518.251.xum Postanaesthetic shivering – from pathophysiology to prevention Maria Bermudez Lopez Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Clinic of Anaesthesia, University Hospital of Lucus Augusti, Lugo, Spain Abstract Postoperative shivering is a common complication of anaesthesia. Shivering is believed to increase oxygen consumption, increase the risk of hypoxemia, induce lactic acidosis, and catecholamine release. Therefore, it might increase the postoperative complications especially in high-risk patients. Moreover, shivering is one of the leading causes of discomfort for postsurgical patients. Shivering is usually triggered by hypothermia. However, it occurs even in normothermic patients during the perioperative period. The aetiology of shivering has been understood insufficiently. Another potential mechanism is pain and acute opioid withdrawal (especially with the use of short-acting narcotics). Besides that shivering is poorly understood, the gold standard for the treatment and prevention has not been defined yet. Perioperative hypothermia prevention is the first method to avoid shivering. Many therapeutic strategies for treating shivering exist and most are empiric. Unfortunately, the overall quality of the antishivering guidelines is low. Two main strategies are available: pharmacological and non-pharmacological antishivering methods. The combination of forced-air warming devices and intravenous meperidine is the most validated method. We also analysed different medications but final conclusion about the optimal antishivering medication is difficult to be drawn due to the lack of high-quality evidence. Nevertheless, control of PS is possible and clinically effective with simple pharmacological interventions combined with non pharmacological methods. However, to be consistent with the most up-to-date, evidence-based practice, future antishivering treatment protocols should optimize methodological rigor and transparency. Keywords: postoperative shivering, postanaesthetic complications, hypothermia Received: 10 March 2018 / Accepted: 30 March 2018 Rom J Anaesth Intensive Care 2018; 25: 73-81 during the perioperative period. The aetiology of shi- vering is not understood sufficiently [2]. In addition to Introduction the fact that shivering is poorly understood, the gold Postoperative shivering is a frequent complication standard for the treatment and prevention has not been of anaesthesia; it has been reported to range from 20 defined yet. Because of its importance as a postope- to 70% in general anaesthesia [1]. Shivering is believed rative complication and the lack of evidence about to increase oxygen consumption and increase the risk aetiology and treatment, this narrative review of the of hypoxemia; it might also increase postoperative com- published literature on this topic is necessary. Shivering, plications. Shivering is usually triggered by hypother- a syndrome involving involuntary oscillatory contrac- mia. However, it occurs even in normothermic patients tions of skeletal muscles, is a common and challenging side effect of anaesthesia and targeted temperature modulation [3]. Shivering is a physiologic response to Address for correspondence: Maria Bermudez Lopez, MD, PhD University Hospital of Lucus Augusti cold exposure and the body’s next step in heat preser- Clinic of Anaesthesia vation after peripheral vasoconstriction [4]. Postope- Department of Anaesthesiology, rative shivering (PS) is an involuntary, oscillatory Int Care Medicine and Pain Medicine muscular activity during early recovery after anaes- Street Doctor Ulises Romero no 1, Lugo, Spain thesia. Shivering is defined as the fasciculation of the E-mail: [email protected] face, jaw, or head or muscle hyperactivity lasting longer 74 Bermudez Lopez than 15 seconds [5]. This phenomenon is a common muscle group; 3: gross muscular activity involving the occurrence observed in the postanaesthesia care unit. entire body [14]. Previous studies have reported an incidence of 5% to 65% after general anaesthesia and 30% to 33% after Aetiology epidural procedures [6]. The overall shivering incidence in a recent meta-analysis was 34% [4]. The combination of anaesthetic-induced thermore- gulatory impairment and exposure to a cool envi- Pathophysiology aspects ronment makes most unwarmed surgical patients hypothermic. Shivering is usually triggered by hypo- The fundamental tremor frequency on the electro- thermia. However, it occurs even in normothermic myogram in humans is typically near 200 Hz. This basal patients during the perioperative period. The aetiology frequency is modulated by a slow, 4-8 cycles/ min, of shivering has not been understood sufficiently [1]. waxing-and-waning pattern [7, 8]. In 1972 Soliman et While cold induced thermoregulatory shivering remains al. found two different patterns of shivering: a tonic an obvious aetiology, the phenomenon has also been pattern similar to normal shivering, and a phasic wave attributed to numerous other causes: pain, disinhibited pattern similar to a pathologic clone. In 1991, Sessler spine reflexes, decreased sympathetic activity, et al. published that both patterns (tonic and clonic) respiratory alcalosis. The conventional explanation for were thermoregulatory in volunteers [8, 9]. The tonic postanaesthetic tremor is that anaesthetic induced pattern showed a constant sinusoide form of normal thermoregulatory inhibition abruptly dissipates, thus shivering and it seems to be a thermoregulatory answer increasing the shivering threshold towards normal. to the intraoperative hypothermia. By contrast, the Discrepancy between the persistent low body tempera- clonic pattern is not a normal component of thermo- ture and the now, near-normal threshold activates regulatory shivering and it seems to be specific of simple thermoregulatory shivering. Difficulties with this recovery from volatile anaesthesia. This pattern of proposed explanation include the observations that shivering might come from the lost of inhibition tremor frequently is not observed in markedly hypo- produced by general anaesthesia in the control of spinal thermic patients and that tremor occurs commonly in reflexes. normothermic patients [15]. Shivering is elicited when the preoptic region of the Perioperative hypothermia is defined as a core tem- hypothalamus is cooled. Efferent signals mediating perature, 33°C to 35°C, while the shivering threshold shivering descend in the medial forebrain bundle. Spinal in nonanaesthetized patients is 35.5°C. Anaesthetic alpha motor neurons and their axons are the final agents increase the heat response thresholds and de- common path for both coordinated movement and crease the cold response thresholds so that the normal shivering [10]. A typical cold tremor has a specific interthreshold range (hypothalamic set point) is rhythm in the form of grouped discharges in the increased [16]. However, the study of Sessler et al. electromyography. During continued cold stimulation [8] suggested that special factors related to surgery, of the skin or the spinal cord, motor neurons are re- stress or pain, might contribute to the genesis of post- cruited in a sequence of increasing size, starting with operative tremor because they failed to identify any the small gamma motor neurons that are followed by shivering-like activity in normothermic volunteers. Pain the small tonic alpha motor neurons, and finally, the might facilitate shivering in both postoperative patients larger phasic alpha motor neurons [11, 12]. and in women having spontaneous term labor. The In other studies with surgical patients, not volunteers, mechanism of thermoregulation is tightly linked to other research demonstrated a different incidence of non homeostatic systems, including the control of pain. Pain thermoregulatory shivering in normothermic postope- and temperature signals are transmitted along similar rative patients [13]. A tonic stiffening pattern of mus- fibber systems that synapse in dorsal horn regions. cular activity was observed as a non-temperature- Rostral ventromedial medulla regulates analgesia to dependent effect of isoflurane anaesthesia. Another noxious stimuli and has a thermoregulatory response observed pattern was a spontaneous electromyogra- to peripheral warming and cooling. One of the important phic clonus that required both hypothermia and residual functions of the rostral ventromedial medulla is to isoflurane end-tidal concentrations between 0.4 and modulate the amount of pain and temperature input 0.2% [8]. ascending from the spinal cord by gating the trans- Mathew et al. describe the following shivering score mission of neuronal signals at the level of the dorsal which assesses the severity of shivering. 0: no shiver- horns [17]. In general, instead of the commonly held ing; 1: mild fasciculations of face and neck and electro- view of a single thermoregulatory integrator (i.e., the cardiography (ECG) disturbances in the absence of preoptic area of the hypothalamus) with multiple inputs voluntary activity of the arms; 2: visible tremor in the and outputs, modern concepts include integrators for Postanaesthetic shivering 75 each thermoregulatory response. Furthermore, these glycine as an additive in the remifentail dose could integrators are distributed among numerous levels directly stimulate NMDA receptors and prophylactic within
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