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Indian J. Anaesth. 2007; 51 (1) : 28 - 31 INDIAN JOURNAL OF ANAESTHESIA, FEBRUARY 2007
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CLINICAL INVESTIGATION

TRAMADOL FOR CONTROL OF SHIVERING

(COMPARISON WITH PETHIDINE)
Dr. Aditi A. Dhimar 1 Dr. Mamta G. Patel 2 Dr. (Mrs.) V. N. Swadia 3

SUMMARY
Shivering is common problem faced by an anaesthesiologist during intraoperative as well as in postoperative period. Shivering occurs
during both general anaesthesia and regional anaesthesia, but it is more frequent and troublesome during regional anaesthesia. This
randomized, prospective study conducted in 60 ASA grade I, II, or III patients, was designed to explore the efficacy and potency
of Tramadol in comparison to Pethidine for control of shivering under regional anaesthesia. Patients received Tramadol or Pethidine
in a dose of 1mg.kg-1 I.V after the appearance of shivering. Disappearance and recurrence of shivering, as well as haemodynamics were
observed at scheduled intervals. Onset of disappearance of shivering was found at 1 minute in Tramadol group (T)( p < 0.05) and
at 3 minutes in Pethidine group (P)( p < 0.05 ). The complete disappearance of shivering took 5 minutes in T group while 20 minutes
in P group.Reccurence rate of shivering was 10% in T and 50% in P group patients respectively (p < 0.05). None of the patients
had any complications except nausea and vomiting (6.6% and 20% in group T and P respectively, p> 0.05). Thus Tramadol and
Pethidine were equally efficacious, but Tramadol was more potent with respect to control of shivering and its recurrence .It was
concluded that I.V Tramadol is qualitatively superior to Pethidine for control of shivering.
Keywords : - Shivering, Tramadol, Pethidine, Regional anaesthesia.

Introduction and are not practical in all the settings. Pharmacological

Regional anaesthesia is a safe and popular anaesthetic
technique for various surgeries. Around 40-60% of the
patients under regional anaesthesia develop shivering.1,2
Shivering can be very unpleasant and physiologically
stressful for the patients after enjoying the comforts of
modern anaesthetics. Mild shivering increases oxygen
consumption to a level that is produced by light exercise,
whereas severe shivering increases metabolic rate and
oxygen consumption up to 100-600%. It may induce arterial
hypoxemia, lactic acidosis, increased IOP and ICT and
interferes with ECG monitoring, pulse rate, B.P etc.3,4,5
Shivering may be detrimental to the patients with low
cardiorespiratory reserves.6 It is uncomfortable to the
parturients as well as to the operating room personnel,
especially during regional anaesthesia.7
Various methods are available for the control of
shivering during anaesthesia.
Non-pharmacological methods using equipments to
maintain normothermia are effective but may be expensive
1. M.D., Asst. Prof.
2. M.D., Asst. Prof.
3. MD., D.A., Prof. and Head
Dept. of Anaesthesiology,
Medical College and S.S.G.Hospital, Vadodara.
Correspond to :
Dr. Aditi A. Dhimar.
26, Shaishav colony, B/H Yash complex,
Gotri Road, Vadodara - 390021.
(Accepted for publication on 08-12-2006)
methods using various drugs like Pethidine, Clonidine,
Doxapram, Ketanserine, Tramadol, Nefopam etc. have
been tried which are simple, cost effective and easily
available. Here we have compared Tramadol, a newer
synthetic opioid with Pethidine, the gold standard drug for
the treatment of shivering, in the quest for more safer and
efficacious drug. We conducted this study to compare the
efficacy, potency, haemodynamics effects and complications
or side effects of Tramadol with that of Pethidine for the
control of shivering.
Materials and methods
A prospective double blind randomized study was
conducted at Medical college and S.S G Hospital Vadodara.
After obtaining approval from the ethical committee a
total of 60 patients from either gender, aged between
20-60 yrs, of ASA PS I, II or III undergoing various
surgeries under regional anaesthesia were taken for the
study. Sample size chosen for the study was based on assuming
the power of 80%, ? value of 0.05 and statistically significant
difference between the two groups. Patients with fever,
thyroid disease, obesity, diabetes, drug allergy, compromised
cardiorespiratory conditions and patients on long term
phenothiazines and MAO inhibitors were excluded from the
study.
After premedication in the form of inj. Atropine or
Glycopyrrolate I.V. Baseline preoperative axillary
temperature was noted in all the patients. Central neural
blockade (Spinal, Epidural And Combined Spinal and
Epidural) or peripheral neural blockade was given according
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DHIMAR, PATEL, SWADIA : TRAMADOL FOR CONTROL OF SHIVERING 29

to the surgical procedures. Patients who experienced

Table - 3 : Demographic data ( Contd..)
shivering of grades as shown in the table 1 were enrolled
for the study. Tramadol Pethidine Z P
(N=30) (N=30)
Table - 1 : Shivering grades.
Axillary 36.1 + 0.3 36.2 + 0.4 0.05 >0 . 0 5 NS*
Grade 0 No Shivering. Temp ( o C )

Grade 1 Mild fasciculations of face or neck, ECG disturbances in Shivering grade 2.27 +0.449 2.3 + 0.466 0.914 >0 . 0 5 NS*
absence of voluntary activity of arms.
Duration of 2.22 + 0.81 2.08 + 0.82 0.316 >0 . 0 5 NS*
Grade2 Visible tremors involving more than one group of muscle. Surgery (hrs)

Grade3 Gross muscular activity involving the entire body, bed shaking * N S = Statistically not significant.

The onset of disappearance of shivering was found at

All the patients who experienced shivering were
around 1minute and 3 minutes in Group T and Group P
randomly divided into Group T and Group P. Group
respectively. Regarding the disappearance of shivering in
T received 1% Tramadol in a dose of 1 mgkg -1and Group
both the groups ,we found a statistically significant difference
P received 1% Pethidine in a dose of 1 mgkg -1. All the
as shown in the table-4 and graph-1. Stoppage of shivering
patients were assessed for shivering grades, its disappearance,
occurred earlier in Group T in comparison to Group P
haemodynamic status, and complications if any. Patients
(P<0.001) as shown in Table 4.
were observed at intervals of 1 min till 5 mins, and thereafter
at 10,20, 30, 45,and 60mins.Pulse rate, B.P, SPO 2 ,
Table – 4 : Control of shivering
Respiratory rate, and temperature were noted immediately
after regional anaesthesia, and also during shivering, TIME Tramadol Pethidine Z P
(Minutes) (N=30) (N=30)
and thereafter the drug administration at regular
intervals. Recurrence of shivering was also noted and an 1 16(53.33%) 1(3.33%) 5.15 <0.05 *S
additional dose of either Tramadol or Pethidine in a dose 3 27(90%) 7(23.33%) 7.05 <0.05 *S
of 0.5 mgkg -1 .was given in respective groups. Statistical
5 30(100%) 16(53.33%)
analysis was done by EPI infoversion 6.04 January 2001
software package using unpaired student ‘ t’ test and chi 10 30(100%) 25(83.33%)
square test. 20 30(100%) 30(100%)

Results 30 30100%) 30100%)

In our study, both the groups were comparable with 40 30(100%) 30(100%)
regards to age, weight, gender, and ASA physical status. 50 16(53.33%) 21(70%)
(table 2).
60 27(90%) 23(76.66%)

Table - 2 : Demographic data. *S = Statistically significant

Tramadol Pethidine Z P Haemodynamically there was no significant difference

(N=30) (N=30) found between the two groups as shown the Table-5.
Age(Yrs) 36.86±13.79 37±13 0.04 >0 . 0 5 NS* Table - 5 : Haemodynamics.
Sex( M:F) 19: 11 21:9 - >0 . 0 5 NS* Tramadol Pethidine Z P
(N=30) (N=30)
Weight (Kgs) 48.33±8.33 46.6±6.34 1.20 >0 . 0 5 NS*
Pre Mean BP 118.6+ 10.94 119.0+ 13.0 0.660 >0 . 0 5 NS*
ASA PS (I:II) 14:16 13:17 - >0 . 0 5 NS*
shivering Mean PR 83..93 + 7.05 85..0 + 7 . 0 0.020 >0 . 0 5 NS*
* N S = Statistically not significant.
During Mean BP 117.8+ 10.42 117.0+ 10.0 0.159 >0 . 0 5 NS*
There was no significant difference found in the
shivering Mean PR 8 8 . 2 3+ 7.67 90..0 + 6 . 4 1.696 >0 . 0 5 NS*
duration of surgery, axillary temperature as well as
shivering grades at the start of study between the two Post Mean BP 118.93+ 11.37 119.0 + 9.7 0.610 >0 . 0 5 NS*
groups (Table 3). shivering Mean PR 85.0 + 7.04 85.0 + 7.01 0.209 >0 . 0 5 NS*

* N S = Statistically not significant

BP= Blood pressure. PR= Pulse rate
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30 INDIAN JOURNAL OF ANAESTHESIA, FEBRUARY 2007

The recurrence of shivering was observed infusion of cold i.v fluids, direct effect of cold anaesthetic
approximately after 50 minutes and the incidence of solution upon the thermosensitive structures of spinal cord
(7,9). Shivering may represent an inappropriate programmed
recurrence was 50% in Pethidine group while only in 10%
in Tramadol group as shown in Table-6. thermal response to rise in body temperature.9 Even local
anaesthetic introduced into the extradural space might modify
Table – 7 : Recurrence and complications. environmental thermal clues, with resultant inappropriate
thermal responses to false information.10 Shivering increases
Tramadol Pethidine oxygen requirement by 100-600%, causes arterial hypoxemia,
(N=30) (N=30) Z P
lactic acidosis, increase in BMR, I.O.P, ICT, and may
Recurrence 3(10%) 15(50%) 8.207 <0.05 S* prove detrimental to patients with low cardiorespiratory
reserve. The parturients experienced it to be uncomfortable
Nausea and
vomiting 2(6.66%) 6(20%) 1.298 >0 . 0 5 NS* after enjoying the benefits of modern anaesthesia.
*NS= Statistically not significant Various nonpharmacological and pharmacological
*S= Statistically significant methods have been used to prevent body heat loss.
Nonpharmacological methods like electrical heaters, forced
3

S air warmers, blankets, radiant heat, and warming the

H operating room suite. The use of warm local anaesthetic
I 2.5

V solutions or warming of i.v fluids are also effective to

E
2
reduce shivering. 11,12 Pharmacological methods using
R
I Ketanserine Nefopam, Pethidine, Alfentanyl, Doxapram,
N
1.5 Gr-T
Tramadol, Clonidine etc have been tried and compared by
G
Gr-P many studies. These drugs are used effectively when
G
1
clinically indicated and they are easily available to all
R
A centers and prove to be practical in the many settings.
D
E
0.5
In our study we have compared recently introduced
S synthetic opioid Tramadol with Pethidine, which was gold
0
0 1 2 3 5 10 15 20 30 45 60
standard for control of shivering. Tramadol a synthetic
opioid agonist prevents shivering by inhibiting the reuptake
Time in Minutes of norepinephrine and serotonin, hence activating the
descending inhibitory spinal pathways. It also modulates the
Graph - 1 : Profile of Shivering and its Control
activity of nucleus median raphe acting centrally on the m
opioid receptors predominantly with minimal effects on
After repeating the drug shivering had disappeared k and d receptors where as Pethidine acts mainly through
completely. Complications like nausea and vomiting occurred opioid receptors namely k? receptors. The mechanism of
in 20% in Pethidine group while only 6.66% in Tramadol action of Tramadol is different from that of Pethidine.
group. However the difference is statistically Tramadol has minimal effect on k? receptors. The
insignificant.(P> 0.05). antishivering effect of Tramadol is mediated via serotonergic
or noradrenergic receptor or both.6,13 Pethidine controlled
Discussion shivering better than Fentanyl and Morphine.14 Therefore
Regional anaesthesia including central neural blockade we undertook a study to compare a newer agent with a
and peripheral nerve blockade is a safe and popular technique time-tested drug.
for various surgeries. Around 40-60% of the patients under
In our study we observed that shivering disappeared
regional anaesthesia develop shivering, though it is found
by 1 minute in case of Tramadol and 5 minutes in case of
commonly after general anaesthesia. 8 The probable
Pethidine and in comparison to earlier study, shivering
mechanism under regional anaesthesia could either be a
reduced significantly at 1 minute after Tramadol but the
result of decrease in core body temperature or misinformation
dose was 2 mgkg -1.3 Furthermore, the complete disappearance
from receptors.9 The factors causing decrease in core body
of shivering took 10 minutes in Tramadol group and
temperature include, sympathetic block causing peripheral
20 minutes in Pethidine group. However in our study the
vasodilation, increased cutaneous blood flow resulting in
complete disappearance of shivering occurred by the end of
increased heat loss through skin, cold operating room, rapid
5 minutes in case of Tramadol and 20 minutes in Pethidine
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DHIMAR, PATEL, SWADIA : TRAMADOL FOR CONTROL OF SHIVERING
group. Earlier studies have showed better results with
Tramadol group.6,15
Regarding recurrence, shivering reappeared after 50
minutes in 10% patients of Tramadol group and 50 % in
Pethidine Group. The difference was statistically significant
( Z=8.207, P<0.05). The findings were in consolence with
other studies which noted 8% with Tramadol group13 and
13-50% in Pethidine group11,13 Thus various studies including
ours there was higher rate of recurrence with Pethidine in
comparison to Tramadol. The second dose of the drug
controlled the shivering completely but the possibility of
respiratory depression with Pethidine should be borne in
mind. The probable reason for recurrence of shivering
could be result of low plasma concentration of the active
drug, when hypothermia is still persisting and individual
variations in the core temperatures. Till date it is not clear
whether higher shivering grades requires a higher doses of
the drug.13
In our study both the drugs gave good and better
haemodynamic stability throughout the course of the study
in all the patients. No respiratory depression was observed
in any of the cases. Only in 20 % of cases from Pethidine
group had nausea and vomiting which was easily treated
with H2 receptor blocker and antiemetic drug. Earlier
studies have found that use of 1 mgkg -1 of Tramadol was
associated with higher incidence of nausea and vomiting,
and also sedation, which was not observed in our study.9
Some others have suggested that slow injection of Tramadol
over 2 minutes, reduces and prevents nausea and vomiting.6
In our study we injected 1% Tramadol and Pethidine I.V
slowly in all the cases.
We can derive at a conclusion that Tramadol is
effective in treating shivering under regional anaesthesia
due to its rapid onset, effective control, less recurrence
rate and minimum side effects in a dose of 1 mgkg -1. when
compared to Pethidine. Similarly Tramadol was effective
and safe in comparison to Pethidine for control of shivering
as noted earlier3,6,11 even recommend for Tramadol on
prophylactic basis also.6
INDIAN JOURNAL OF ANAESTHESIA
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31
References
1. De Whitte, Sessler DI, et al. Perioperative shivering: Physiology
and Pharmacology. Anaesthesiology 2002; 96(2): 467-84.
2. Sessler DI, Jose Ponte, et al. Shivering during epidural
anaesthesia. Anesthesiology 1990; 72: 816-21.
3. Bhatnagar S, Saxena A et al. Tramadol for postoperative
shivering: a double blind comparison with Pethidine. Anesth
Intensive care 2001; 29: 149-54.
4. Katyal Sunil, Tewari Anurag et al. Shivering: Anesthetic
Considerations. J Anaesth Clin Pharmacol 2002; 18(4):
363-76.
5. Sessler Daniel I. Temperature Monitoring. Textbook of
Anaesthesia; Ronald D Miller 5th edition, Churchill Livingstone
Inc. 1994: 1367-89.
6. Mathews S, Al Mulla A et al. Postanaesthetic shivering-a new
look at Tramadol. Anaesthesia 2002; 57: 387-403.
7. Anne Miu Han Chan, Kwok Fu et al. Control of shivering
under regional anaesthesia in obstetric patients with
Tramadol.Can J Anesth 1999; 46(3): 253- 58.
8. Eberhart L H, Roewer N et al. Pharmacological treatment of
postoperative shivering: a quantitative systemic review of
randomized controlled trials. Anesth Analg 2002; 94(2):
453-60.
9. Chaturvedi S, Domkondwar G. Control of shivering under
regional anaesthesia using Tramadol. Asian Archives of
Anaesthesiology and Resuscitation 2002; 57: 491-96.
10. Pamela J, Webb et al. Shivering during epidural analgesia in
women in labour. Anaesthesiology 1981; 55: 706-07.
11. Wrench J Cavill et al. Comparison between Alfentanil,
Pethidine, and placebo in the treatment of postoperative
shivering. Br J Anaesth. 1997; 79: 541-42.
12. Takehiko I, Sessler Daniel I et al. Meperidine and Alfentanyl
do not reduce the gain or maximum intensity of shivering.
Anaesthesiology 1998; 88(4): 858-65.
13. Write J De Deloof, T et al. Tramadol in the treatment of
post anesthetic shivering. Acta Anaesthesiol Scand 1997; 41:
506-10.
14. Singh P, Dimitriou V et al. Double blind comparison between
Doxapram and Pethidine in the treatment of postanaesthetic
shivering . Br J Anaesth 1993; 71: 685-88.
15. Pausawasdi S, Jirasirithum S et al. The use of Tramadol
hydrochloride in treatment of post-anesthetic shivering Med
Assoc Thai 1990; 73: 16-20.
- Editor