ABSTRACT
Background: Shivering is one of the most common unpleasant complications in the postoperative period. Many clinical trials have been published and revealed various efficacious drugs for the treatment of postanesthetic shivering. Objective: To perform an updated quantitative review of randomized controlled trials (RCTs) studying efficacy of pharmacological treatment of post-anesthetic shivering. Methods: We initiated a systematic search for original articles of randomized, controlled studies of drugs for postanesthetic shivering. Reports were appraised, and binary data of shivering within 15 minutes after treatment were extracted. Relative risk (RR) and the number-needed-to-treat (NNT) were subsequently analyzed and then reported with 95% confidence interval (CI). Results: The efficacy of anti-shivering drugs was analyzed by using data from 32 RCTs. Meperidine 25 to 50 mg, tramadol 0.5 to 1 mg/kg, clonidine 30 to 150 μg, ketanserin 10 mg, doxapram 25 to 100 mg, and nalbuphine 0.05 to 0.1 mg/kg, reported in at least two trials, were significantly more effective than placebo within 15 minutes after treatment. The NNT of meperidine 25 to 50 mg was 1.39, of tramadol 0.5 to 1 mg/kg was 1.56, of ketanserin 10 mg was 2.44, of doxapram 25 to 100 mg was 1.82, and of nalbuphine 0.05 to 0.1 mg/kg was 1.75. The efficacy of tramadol 0.5 to 1 mg/kg was not significantly different from meperidine 0.5 mg/kg (25 mg) at 15 minutes of observation (p = 0.34). Moreover, clonidine 30 to 150 μg was more effective in treating tremor than placebo, with the NNT of 1.43. Studies in efficacy of alfentanil, magnesium sulfate, fentanyl, ondansetron, nefopam, pentazocine, urapidil, morphine, lignocaine, metamizol, and butorphanol, were inadequate for quantitative analysis. Conclusion: Meperidine 25 to 50 mg, tramadol 0.5 to 1 mg/kg, clonidine 30 to 150 μg, doxapram 25 to 100 mg, ketanserin 10 mg, and nalbuphine 0.05 to 0.1 mg/kg can effectively treat postanesthestic shivering within 15 minutes. Tramadol 0.5 to 1 mg was found to a be good alternative compared to meperidine 25 to 50 mg. Side effects of treatments were mild and treatable.
ABSTRACT
Background: As a site of the Thai Anesthesia Incidents Study (THAI Study) of anesthetic adverse outcome, we continued the institutional data collection to determine incidence of cardiac arrest, mortality rate and risk factors representing a Thai University hospital. Methods: Between July 2003 and December 2006, an anesthesia registry was conducted at King Chulalongkorn Memorial Hospital. Anesthesiologists were requested to record perioperative variables and adverse outcomes including perioperative mortality (i.e., event of death since the conduction of anesthesia until the end of 24-hour postoperative period) on a structured data-record form. Details of events were reviewed by three independent anesthesiologists who determined the causes by consensus. Logistic regression identified characteristics associated with mortality within 24-hr P \< 0.05 that were considered significant. Results: Among 50,409 cases in the registry, 108 patients experienced perioperative cardiac arrest with 80 fatalities. The incidences of intraoperative, and 24-hr perioperative cardiac arrest were 10.32 and 21.42 per 10000 anesthetics with mortality rate of 48.1% and 74.0% respectively. Factors related to perioperative mortality were; higher ASA physical status [OR 5.92 (95%, CI 4.41-7.95)], emergency surgery [OR 2.48 (95%, CI 1.31-4.70)], intracranial surgery [OR 10.01 (95%, CI 3.35-29.9)] and use of desflurane [OR 6.64 (95 %, CI 2.68-16.4)]. Factors related to lower risk of mortality were: lower abdominal surgery [OR 0.32 (95%, CI 0.13-0.78)], and the use of nitrous oxide [OR 0.38 (95%, CI 0.003-0.19)]. Common characteristic of intraoperative death were: male gender, emergency traumatic condition, upper abdominal surgery. The most common cause of intraoperative death was exangination (60%). The incidence of anesthesia related mortality was 0.198 per 10,000. Conclusion: The incidence of intraoperative and 24-hr perioperative cardiac arrest was 10.3 and 21.4 per 10000 anesthetics with morality rate of 48.1% and 74.0% respectively. Improving emergency trauma facility may increase survival rates.
ABSTRACT
Background: Use of meperidine for the treatment of post-anesthetic shivering (PS) after neuraxial opioids is limited by risk of respiratory depression. Objective: To compare the efficacy of tramadol, nalbuphine, ondansetron and a placebo in the treatment of PS after spinal anesthesia in cesarean section patients. Methods: Two hundred eighty parturients who developed moderate to severe shivering and required treatment after cesarean delivery under spinal anesthesia with bupivacaine and intrathecal morphine 0.2 mg were randomized into 4 groups. Group T, Group N, Group O and Group P were given tramadol 0.5 mg/kg, nalbuphine 0.05 mg/kg, ondansetron 0.1 mg/kg and normal saline 5 mL IV, respectively. The patients were evaluated at 15 minutes after treatment and were observed for a recurrence of PS within 4 hours in a double-blinded fashion. Results: The treatment success rate (no or mild shivering) of PS in groups T, N, O and P were 88, 81, 61 and 36 %, respectively (p \< 0.001). The treatment success rate of groups T vs P, N vs P, O vs P, T vs O and N vs O were significantly different (p \< 0.001, 0.001, 0.003, \< 0.001, and 0.009, respectively). The success rate between groups T vs N was not significantly different (p=0.223). Recurrence rate of PS in groups T, N, O and P were 14 %, 15 %, 11 % and 28 %; p=0.329. Other side effects such as pruritus, nausea/vomiting, and dizziness were few and treatable. Conclusion: Tramadol, nalbuphine and ondansetron were efficacious in the treatment of PS after intrathecal morphine in cesarean section patients with low recurrence rates. Tramadol and nalbuphine were superior to ondansetron in the treatment of PS.