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The Effect of Dexmedetomidine Prescription on Shivering During Anesth Pain Med. 2018 April; 8(2):e63230. doi: 10.5812/aapm.63230. Published online 2018 April 25. Research Article The Effect of Dexmedetomidine Prescription on Shivering during Operation in the Spinal Anesthesia Procedures of Selective Orthopedic Surgery of the Lower Limb in Addicted Patients Mahshid Ghasemi,1 Faranak Behnaz,2,* and Habibollah Hajian3 1Assistant Professor of Anesthesiology, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2Assistant Professor of Anesthesiology, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran 3Anesthesiologist, Shahid Beheshti University of Medical Sciences, Tehran, Iran *Corresponding author: Faranak Behnaz, M.D, Assistant Professor of Anesthesiology, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. E-mail: [email protected] Received 2017 October 24; Revised 2018 March 11; Accepted 2018 April 04. Abstract Background: Shivering during a surgery is common. Recently, Alpha-D-agonist dexmedetomidine has been used to control and prevent shivering during and after surgery. However, the anti-shivering effects of this drug in people are unknown with substance abuse. The purpose of this study was to investigate the anti-shivering effect of this drug in addicted individuals. Methods: After obtaining the required criteria, the criteria were randomized in 2 groups, dexmedetomidine and normal saline (each group n = 30), and were matched in age and sex. The dexmedetomidine 0.5 mg/kg/h was given to one group and normal saline infusion was given to the other group as a placebo immediately after induction of anesthesia and before surgery for lower limb lesions. During the operation, patients were monitored for shivering as well as vital signs and arterial oxygen saturation. In addition, after surgery, patients were evaluated for clinical side effects. Results: The results showed that systolic blood pressure was significantly lower in the dexmedetomidine group at 30 minutes to 150 minutes after injection during the operation (P < 0.01). There was no significant difference between the 2 groups at the other times. In intra-group comparisons in both groups, diastolic pressure drop was significantly decreased to 90 minutes after surgery. In general, at other times in each group, diastolic pressure changes were not significant compared to preoperative. In between group comparisons, the mean heart rate was significantly lower in the dexmedetomidine group at 30 minutes and 60 minutes compared to the control group. In addition, at other times, its lower values were not significantly different with the control group. The 2 groups did not show significant differences in the number of breaths per minute or as the intra-group (P > 0.05), although, the average respiratory rate per minute in the dexmedetomidine group was lower. Decreased temperature of the tympanic curvature was significantly lower in the DEX group at 10 and 60 minutes after surgery than the control group (P < 0.001). Arterial oxygen saturation was more than 97% in both groups before and after operation, and no difference was observed between the 2 groups. Conclusions: Prescribing dexmedetomidine during spinal anesthesia in patients with substance abuse can significantly decrease the incidence of shivering during surgery while not having adverse effects on hemodynamics of patients and can be used as a safe and effective drug for this purpose. Keywords: Anesthesia, Addiction, Dexmedetomidine, Shivering, Drug Abuse 1. Background caused by hypothermia (0.5 - 1°C decrease in central heat- ing) has been accepted as the most common factor (2). Shivering in surgery is a common and unpleasant com- Shivering interferes with pulse oximetry monitoring, plication during the operation, occurring in 6% to 65% measurement of blood pressure and ECG, and increases of patients, including involuntary movements of one or oxygen consumption up to 5%, which in turn increases more muscle groups (1). However, various causes such as the need for cardiac output and respiratory ventilation, pain, decreased sympathetic activity, uncontrolled spinal which can be found in older patients or in patients with reflux, release of pyrogen, cytokines following surgery, or a disease of cardio respiratory tract that causes respira- adrenal suppression, etc. have been suggested as causative tory heart failure (3). Shivering also causes lactic acidosis, factors of shivering, however, thermo-regulation disorders increases carbon dioxide production and muscle fatigue, Copyright © 2018, Anesthesiology and Pain Medicine. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited Ghasemi M et al. and increases the internal pressure of the eye (IOP) and in- more analgesic analysts than non-compliant patients dur- tracranial pressure (ICP). In patients undergoing surgery, ing and after surgery (13). In addition, according to a study shivering increases the pain in the site (2,3). It is important conducted so far, no study has been conducted to evaluate to note that the incidence of shivering in regional anes- the anti-shivering effect of this drug in patients with sub- thesia is not less than general anesthesia and patients’ hy- stance abuse. pothermia continues until the blocking effects disappear below the block level. In regional anesthesia, not only is 2. Objectives posting sensory signals from the lower limbs to the im- paired centers of nervous system is disturbed, but due to The purpose of this study was to investigate the effect the paralysis of the muscles of the lower limbs, the actual of dexmedetomidine prescription on the incidence of shiv- production of heat decreases. As a result, in regional anes- ering during surgery in a spinal anesthetic technique un- thesia, the patient’s re-warm-up period is approximately der elective orthopedic surgery of the lower limb in ad- twice in comparison to common anesthesia (3,4). dicted patients. Today, various pharmaceutical and non- pharmaceutical solutions have been devised and used 3. Methods to prevent and treat hypothermia as well as shivering. Non-pharmacological methods include the prevention The study was a double blind randomized clinical trial. of hypothermia using warm-up blankets and inhaling The population under study was a candidate addicted pa- hot and humid oxygen, keeping the patient warm before tient for lower limb orthopedic surgeries referring to the and during operation, and preventing the operation operating room of Taleghani Hospital affiliated to Shahid room from cooling down. As noted, one of the non- Beheshti University of Medical Sciences in 2015. According pharmacological methods is to warm the skin, due to to similar studies and bass on α = 0.5, β = 0.8, (d = µ1 - µ2 the fact that the body’s heat regulation system tolerates = 1.2), according to the following formula, the sample size the central body hypothermia when the skin is warmed; was estimated at around 21 people. However, in order to however, this method is effective when the temperature of achieve better results, 30 people were considered for each the central part of the body is greater than 35 °C (5). group. Pharmaceutical methods mainly affect the decrease 2 2 2 of the shivering temperature threshold. Various medica- Z α + Z1−β σ + σ 1− 2 1 2 tions such as meperidine, clonidine, ketanserin, magne- n = 2 (1) (µ1 − µ2) sium sulfate, physostigmine, and etc. have been used to treat shivering. Each of these drugs, although effective in The sampling method was simple non-random. All el- decreasing shivering with various mechanisms, has been igible individuals were selected accordingly, in order to shown to have unwanted side effects, such as reducing complete the sample. They were randomly divided into consciousness and weakening of the respiratory center, as 2 groups of 30 patients with dexmedetomidine and nor- well as causing nausea, vomiting and itching, which is un- mal saline (control). The following entrance criteria were pleasant for the patient, surgeon and an anesthetist during included in the present study: abuse of substances dur- surgery and will sometimes be life-threatening to the pa- ing the past 6 weeks (14), the history of opioid addic- tient (6). Therefore, considering the probable occurrence tion (an inhaler used in opium and 2 peas or 390 mg per of these complications, alternative drugs have always been day), ages 18 to 55 years, ASA I-II, lower limb orthopedic considered for the prevention and treatment of postoper- surgery under spinal anesthesia, lack of underlying dis- ative shivering. In recent studies, the effect of dexmedeto- ease, such as ischemic heart diseases, diabetes mellitus, midine on shivering has been continued to study and stud- and hypertension, body temperature within normal lim- ies in this area (7-9). Dexmedetomidine, an alpha-2 ago- its, absence of sweating, seizures, tremor or Parkinson’s, nist, is a relatively new sedative drug approved by the FDA lack of taking NSAIDs 24 hours before surgery, absence of and approved for use up to a maximum of 24 hours at a contraindications of dexmedetomidine prescription and maximum dose of 0.7 µg per kg body weight per minute. absence of side effects after taking dexmedetomidine, lack Alpha-2 agonists have been shown to have analgesic prop- of or wound infection, there is no known allergies, the ab- erties. In addition, dexmedetomidine is used in humans sence of pregnancy and lactation, and duration of surgery for safe and effective central and peripheral blocks (10) and up to 3 hours. Patient satisfaction and exclusion crite- is widely used in intensive care units (11, 12). Consider- ria include: complications requiring intervention within ing the tolerance of addicted patients to narcotic drugs 24 hours after surgery, patients receiving blood during and taking into account the fact that these patients need surgery and anesthesia, and reducing the patient’s central 2 Anesth Pain Med.
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