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Inadvertent postoperative hypothermia is common among hypothermia and 24.7% experienced shivering, which was
patients in the postanesthesia care unit (PACU). Shivering observed primarily in hypothermic patients. Mean arterial
traditionally is attributed to hypothermia, but it is not blood pressure was significantly higher in hypothermic
always thermoregulatory. The exact impact of hypothermia patients, and heart rate was significantly higher in shiver-
and shivering on standard PACU monitoring parameters of ing patients, whereas oxygen saturation was not affected
patients has not been sufficiently studied. by hypothermia or shivering.
The present study included 170 orthopedic surgical Our data confirm that standard PACU monitoring param-
patients. On PACU arrival, we recorded the incidence of eters are affected partially by hypothermia and shivering. A
hypothermia and shivering, as well as heart rate, mean arte- low incidence of shivering in normothermic patients and a
rial blood pressure, and oxygen saturation of all subjects. high incidence of shivering in younger patients are dis-
cussed. Limitations of this study are reported.
Analysis of covariance was used to investigate the effects of
hypothermia and shivering on these monitoring parameters. Key words: Core temperature, hypothermia, orthopedic
Among orthopedic patients, 73.5% of them had patients, shivering, standard PACU monitoring.
Hypothermic Normothermic
patients (n = 125) patients (n = 45) P
Age (y) 55.1 ± 15.4 50.5 ± 19.3 .11
Sex (M/F) 51/74 16/29 .54
Anesthetic technique(general/regional 85/40 28/17 .48
[spinal or spinal-epidural] )
ASA classification (1-2/3-4) 103/22 39/6 .51
Total time in operating room (min) 157.5 ± 25.6 146.9 ± 25.0 .02
Operating room temperature (°C/°F) 22.8 ± 1.8/73.0 ± 3.2 23.1 ± 1.9/73.6 ± 3.4 .28
Shivering Non–shivering
patients (n = 42) patients (n = 128) P
Age (y) 48.4 ± 14.2 55.7 ± 16.9 .01
Sex (M/F) 16/26 51/77 .84
Anesthetic technique (general/regional 27/15 86/42 .73
[spinal or spinal-epidural] )
ASA classification (1-2/3-4) 38/4 104/24 .16
Total time in operating room (min) 160.5 ± 27.0 152.8 ± 25.2 .09
Operating room temperature (°C/°F) 22.6 ± 1.9/72.6 ± 3.4 23.0 ± 1.8/73.4 ± 3.2 .33
Table 3. Hypothermia and shivering among patients in the postanesthesia care unit
Shivering Non–shivering
patients (n = 42) patients (n = 128) P
Hypothermic patients (n = 125) 38 (30.4%) 87 (69.6%)
.01
Normothermic patients (n = 45) 4 (9%) 41 (91%)
patients. After removing the covariance of preopera- very rare, only 8.9%. Horn et al25 reported a relatively
tive values of monitoring parameters, only the mean high incidence of shivering, 27%, in normothermic
arterial blood pressure was affected by hypothermia patients after major orthopedic surgery. Such differ-
(F = 5.248; P = .02), and only heart rate was affected ences observed between similar studies might be
by shivering (F = 4.696; P = .03); oxygen saturation attributed to different patient characteristics in the
was affected by neither. Postoperative adjusted mean studies.
arterial blood pressure of hypothermic patients was The mean age of shivering patients was signifi-
significantly higher than that of normothermic cantly younger, which is consistent with the findings
patients (mean ± SE, 102.9 ± 0.8 mm Hg vs 97.6 ± 1.2 of other studies.11,35 Advanced age impairs thermoreg-
mm Hg). The postoperative adjusted heart rate of ulatory responses, in the presence and absence of
shivering patients was significantly higher than that of anesthesia. Ozaki et al36 showed a lower vasoconstric-
non–shivering ones (73.4 ± 0.9 beats per minute vs tion threshold in older patients during general anes-
68.5 ± 1.4 beats per minute). thesia. The shivering threshold also may be lowered
with age.
Discussion • Standard PACU monitoring. In the present study,
• Hypothermia and shivering. The incidence of only mean arterial blood pressure was affected by
hypothermia in postoperative orthopedic patients was hypothermia. Frank et al30 reported a lower heart rate
high, at 73.5%. Kean34 observed that orthopedic oper- and higher arterial blood pressures (systolic, mean,
ating rooms had the lowest ambient temperatures, and diastolic) in hypothermic patients during the
with orthopedic patients showing a high incidence of early postoperative period. However, they studied rel-
hypothermia. When no efficient preventive measures atively old patients with 2 or more risk factors for
are taken during the operation, hypothermia occurs, coronary artery disease. Kurz et al20 studied young
even after minor surgical procedures. and healthy patients and found no difference in post-
Our findings confirm that postanesthetic shivering operative heart rate and arterial blood pressure
is, for the most part, thermoregulatory. However, it between hypothermic and normothermic patients.
also was observed in normothermic patients, and this Hypothermia may cause hypertension due to cate-
supports the hypothesis that other factors may cause cholamine action and vasoconstriction, but the degree
non–thermoregulatory tremor. In the patients we of core temperature decrease, which is necessary for a
studied, the incidence of this type of shivering was significant increase in blood pressure, is not known.
Hypothermic Normothermic
patients patients F P
Heart rate (beats/min) 70.4 ± 1.1 68.0 ± 1.5 1.269 .26
Mean arterial blood pressure (mm Hg) 102.9 ± 0.8 97.6 ± 1.2 5.248 .02
Oxygen saturation of arterial blood (%) 96.9 ± 0.3 97.2 ± 0.4 0.406 .52
Table 5. Analysis of covariance of standard PACU monitoring parameters between shivering and non–shivering
patients (on PACU arrival)
In orthopedic patients, although the core temperature ering threshold without compromising ventilation,
decrease was rather small, the mean arterial blood causing sedation, or altering the vasoconstriction
pressure was affected significantly. threshold.38
Heart rate was the only parameter affected by the During anesthesia, there is a potential for continu-
presence of shivering. Heffline33 also reported a sig- ous drug administration, such as volatile anesthetics
nificant reduction in heart rate and arterial blood (sevoflurane) and intravenous analgesic drugs
pressure at the end of shivering. It seems that, in (remifentanil). These drugs offer us the advantage of
combination with hypothermia, shivering possibly continuous regulation of heart rate and arterial blood
results in an increased metabolic rate, tachycardia, pressure, which can be maintained within narrow lim-
and increased cardiac output. its (according to the baseline values of each patient as
• Implications for nursing practice. Our results con- measured before induction of anesthesia). After awak-
firm that there is an imperative need for intraoperative ening from anesthesia, this regulation potential is lost,
forced-air warming of all patients, regardless of the and standard PACU monitoring parameters can be
type and duration of operation. The purchase and use affected by many factors and rapidly altered during
of many forced-air warmers seems particularly expen- the immediate postoperative period. It is important
sive. However, as Augustine Medical has shown, that PACU nurses are aware of the possible impact of
because hypothermia increases indirect costs (length hypothermia and shivering on the arterial blood pres-
of PACU stay, nursing time, adverse events), the use of sure and heart rate, respectively. Immediate recogni-
forced-air warming actually may reduce overall hospi- tion and intervention are critically important in
talization costs.37 patients with chronic cardiovascular diseases because
Shivering usually comes as a result of postoperative hemodynamic instability can lead to serious compli-
hypothermia, so its primary treatment should involve cations during the postoperative period (even life-
rewarming. However, because other factors contribute threatening complications, such as myocardial
to the manifestation of shivering, rewarming always ischemia).
should be combined with the intravenous administra- • Limitations. Some, possibly inevitable, limitations
tion of drugs. Opioids (morphine or meperidine) have of our study are the following: (1) The design was
suppressed shivering in 2 to 5 minutes.11 Nefopam, a quasi-experimental. Subjects were not randomly allo-
new analgesic agent, can significantly reduce the shiv- cated in 2 homogeneous groups but were divided