Post-Anesthesia Shivering

RUNNING HEAD: A COMPARATIVE STUDY ON POST-ANESTHESIA SHIVERING

A Comparative Study on Post-Spinal Anesthesia Shivering

Terra Conkle, Tara Esker Diana Hughes, Ember Knapp Stacey Lucas, Emily Plum Margaret Tanner

Department of Nursing Kent State University East Liverpool

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Abstract The study conducted by Shukla, Malhotra and Prabhaker (2011) focuses on a treatment for postspinal anesthesia. The use of anesthesia can have a negative effect on human body temperature. Therefore, the body will drastically decrease its core temperature. In previous research, patients have experienced shivering, impaired coagulation and prolonged drug action (Sessler 1993). Post-spinal anesthesia shivering is a wide-spread complication that patients complain about after surgery. In fact, many patients have reported the shivering to be worse than the pain they felt from surgery (Shukla et al. 2011). In this particular study, Shukla et al. (2011) are looking at the effects of two medications (clonidine and tramadol) administered to patients who received a regional spinal anesthetic for their surgeries.

A Comparative Study on Post-Spinal Anesthesia Shivering

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Indian researchers Shukla, Malhotra and Prabhaker (2011) conducted a study focusing on a treatment for post-spinal anesthesia. The use of anesthesia can negatively affect the control of body temperature (Sessler 1993). In most cases, patients under anesthesia for 3 to 4 hours will have a drastic decrease in body temperature (Sessler 1993). When the body experiences extensive heat loss, thermoregulatory vasoconstriction is triggered; thus decreasing the bodys core heat (Sessler 1993). This particular type of hypothermia produces many adverse effects. For example, patients have experienced severe vasoconstriction, shivering, impaired coagulation, prolonged drug action and negative postoperative nitrogen balance (Sessler 1993). In previous studies, patients have reported the cold sensation that comes with shivering to be worse than the pain associated with surgery (Shukla et al. 2011). Post-spinal anesthesia shivering, a widespread post-operative complication has been reported in 40-70% of patients who have received regional anesthesia (Shukla et al. 2011). Shukla, Malhotra and Prabhaker (2011), studied the anti-shivering effects of clonidine and tramadol in postoperative patients who received regional anesthesia. The study conducted by Shukla, Malhotra and Prabhaker (2011), selected patients who would be administered spinal anesthesia. This regional anesthesia is when a local anesthetic is injected into the CSF in the subarachnoid space (Lewis 362). This anesthesia is usually injected below the L2 level (Lewis 362). After the injection, the anesthetic mixes with the CSF, which can achieve different levels of anesthesia (Lewis 362). This produces autonomic, sensory, and motor blockade (Lewis 362). The autonomic blockade causes vasodilation, which may result in hypotension. Eventually, the sensory block causes the patient to feel no pain (Lewis 362). Therefore, the motor block makes the patient unable to move (Lewis 362). Two forms of treatment were used in the study conducted by Shukla, Malhotra and Prabhaker (2011). In previous studies, researchers have found that the drugs clonidine and

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tramadol help treat post-spinal anesthesia shivering (Sia 1998; Dhimar and Swadia 2007). Therefore, these two drugs were chosen in the Shukla et al. (2011) study. The drug clonidine is an antihypertensive (central acting alpha2 receptor agonist) (Lilley 166; 388). The primary use of clonidine is to decrease blood pressure and decrease thermoregulatory vasoconstriction (Lilley 166; 388). As for the drug Tramadol, it is an opioid analgesic (central acting analgesic) (Lilley 166; 388). Tramadol is used for the treatment of moderate to severe pain (Lilley 166; 388). Shukla et al. (2011) have compared the effects of these drugs in their study to treat post-spinal anesthesia. Method Post-spinal anesthesia shivering can be controlled with drugs containing anti-shivering properties, such as clonidine and tramadol (Shukla et al. 2011). In a double-blind clinically controlled study, the effects and complications of both clonidine and tramadol were compared (Shukla et al. 2011). Patients participating in this study were both male and female between the ages of 18 and 40 who were scheduled for elective abdominal, orthopedic, and gynecological surgeries (Shukla et al. 2011). Patients were selected for the study by the following scale: Grade 0: No shivering Grade 1: One or more of the following: Piloerection, Peripheral vasoconstriction, peripheral cyanosis with, but without visible muscle activity

Group 2: Visible muscle activity confined to one muscle group Grade 3: Visible muscle activity in more than one muscle group Grade 4: Gross muscle activity involving the whole body (Shukla et al. 2011).

Only patients with grades of 3 and 4 met the criteria for the study (Shukla et al. 2011). The patients were broken up into two groups of 40; Clonidine was administered to group c, post-

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operatively and tramadol was administered to group t, post-operatively (Shukla et al. 2011). Oxygen was administered to all participants, and vital signs were taken before the surgery for a baseline (Shukla et al. 2011). Vitals where then monitored every 5 minutes for an hour after the surgery, then every 15 minutes for the remainder of observation (Shukla et al. 2011). After the drugs were administered to each group, shivering times were documented from the time the shivering began until it ended. Shukla et al. (2011) documented the length of surgery and spinal anesthesia. Treatment was considered to be ineffective if shivering did not cease in 15 minutes and was observed until the patient left the hospital (Shukla et al. 2011). The participants who continued to experience shivering were administered another dose of the same medication (Shukla et al. 2011). All adverse effects were also documented (Shukla et al. 2011). In the end, the results were analyzed using statistical software, a student t test and a Chi-square test; if a P value of <.05 was obtained it would be highly significant (Shukla et al. 2011).

Results As mentioned above, eighty participants were selected for this study and randomly placed into two even groups of 40 (n=40) (Shukla et al. 2011). Out of the 40 participants who received clonidine, 39 reported that shivering disappeared (Shukla et al. 2011). As for the group who received tramadol, 37 reported that shivering disappeared (Shukla et al. 2011). Overall, the average time between the injection of the drugs (clonidine and tramadol) and the termination of shivering was 2.54 (group c) and 5.01(group t) minutes (Shukla et al. 2011). To illustrate, table 1 shows the difference in the time interval between the two groups. The time interval between drug administration and the decrease in shivering is statistically significant between the two groups. To explain, these results were highly significant because the P value obtained was 0.01,

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which is less than .05 (Shukla et al. 2011). Therefore, the effects of the clonidine began to work in significantly less time than the Tramadol (Shukla et al. 2011). As for the participants not mentioned in the above results, they are the outliers in this study. Between both groups, shivering remained unchanged with four of the participants (group c-1 and group t-3) (Shukla et al. 2011). Overall, six participants in group t; were administered rescue doses of tramadol due to recurring and/or unsubsiding shivering (Shukla et al. 2011). In addition, group t had more complications than group c (Shukla et al. 2011). As shown in table 2 below, the group that received tramadol experienced a higher quantity of adverse effects such as nausea, vomiting, and dizziness (Shukla et al. 2011). In the end, clonidine had more evidence to support its effectiveness in treating post-anesthesia shivering than tramadol with regards to this drugs shorter onset and fewer adverse effects. Discussion Shukla, Malhotra and Prabhaker (2011) discuss different methods used to prevent heat loss and decrease shivering after surgery. In the present study, they attempted to reduce heat loss by maintaining the temperature of the OR between 21C and 23C (Shukla et al. 2011). In addition, IV fluids were administered at room temperature and the temperature of the patients were recorded regularly (Shukla et al. 2011). The present study could not control certain factors; for example, temperatures of the IV fluids and drugs (Shukla et al. 2011). However, they claim it did not affect the outcome of the study (Shukla et al. 2011). On limitation during the study occurred; meaning, core body temperature of the participants could not be measured accurately because the methods would be too invasive for those receiving spinal anesthesia (Shukla et al. 2011). Therefore, the temperature of the participants was taken using the axillary method (Shukla et al. 2011). Overall, researchers tried to maintain as much control of operating rooms,

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how the medications and IV fluids were administered and the participants body temperature to help reduce heat loss as one way of preventing post-spinal anesthesia shivering. In the 2011 study, tramadol and clonidine had similar effects on participants with reducing post-anesthesia shivering. However, the onset of clonidine was significantly faster (Shukla et al. 2011). In addition, when compared with tramadol, the clonidine had fewer adverse effects (Shukla et al. 2011). As mentioned in the results, the tramadol did not have any effect on the participants for approximately 5 minutes (Shukla et al. 2011). In addition, group t experienced a higher amount of adverse effects once the medication took effect (Shukla et al. 2011). Overall, the outcome of the present study correlates with previous research on this particular subject. In the end, both medications clonidine and tramadol were effective treatments for postspinal anesthesia. Based upon the time interval, clonidine was more effective for treating postoperative shivering, as most participants in group c reported that the shivering had subsided within approximately 2 minutes. As a result, Shukla et al. (2011), conclude that clonidine offers more positive effects for regulating body temperature for patients who receive spinal anesthesia. Overall, further research is needed to explore the effectiveness of other medications for treating post-spinal anesthesia shivering.

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Table 1:

Table 2:

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References Ackley, B. J., & Ladwig, G. B. (2011). Nursing Diagnosis Handbook (9th ed). St. Louis, Missouri: Mosby, Inc. Dhimar, D., Patel, D., & Swadia, D. (2007, Feb). Tramadol for Control of Shivering. Indian Journal of Anesthesia, 51(1): 28-31. Lewis, RN, PhD, FAAN, S. L., Heitkemper, RN, PhD, FAAN, M., Dirksen, RN, PhD, S., Bucher, RN, PhD, CEN, L., & Camera, RN, MSN, ND, I. M. (2011). Medical-Surgical Nursing Assessment and Management of Clinical Problems (8th ed). St. Louis, Missouri: Mosby, Inc. Lilley, RN, PhD, L. L., Harrington, PharmD, S., Snyder, MSN, RN-BC, J. S., & Collins, PharmD, S. (2011). Pharmacology and the Nursing Process (6th ed). St. Louis, Missouri: Mosby, Inc.

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Sessler, MD, D. I. (1993, May). Perianesthetic Thermoregulation and Heat Balance in Humans. The FASEB Journal, 7: 638-644. Shukla, U., Malhotra, K., & Prabhaker, T. (2011, May-June). A Comparative Study of the Effect of Clonidine and Tramadol on Post-spinal Anaesthesia Shivering. Indian Journal of Anesthesia, 55 (3): 242-246. Sia, S. (1998, Aug). I.v. Clonidine Prevents Post-extradural Shivering. British Journal of Anaesthesia, 81(2): 145-146. Swearingen, RN, P. L. (2008). All-in-One Care Planning Resource (2nd ed.). St. Louis, Missouri: Mosby, Inc.