Introduction

Hypothermia and shivering are relatively common complications after surgery that can lead to other complications such as increased oxygen need and consumption, increased intraocular and intracranial pressure, and increased pain at the site of surgery due to skin stretching. Some of these complications, especially in patients with ischemic heart disease, can lead to worsening of the patient’s condition. Therefore, prevention of their occurrence and their timely treatment is one of the important goals in anesthesia. Currently, the most commonly used drug in the treatment of postoperative shivering is pethidine, and various other drugs have been studied for its prevention or treatment. Given the side effects of narcotics such as impaired breathing, pruritus, nausea and vomiting, and the unique complication of meperidine use (tachycardia), it makes sense to find an effective drug as an alternative to treating postoperative shivering. In this study, the effectiveness of meperidine in treatment of postoperative shivering was compared with that of ondansetron (a serotonin receptor antagonist).

Materials and Methods

Patients with shivering after general anesthesia for laparotomy were selected as study samples based on the inclusion criteria: metting ASA I, II criteria, age 20-60 years, duration of surgery between 2-3 hours, no history of liver disease, heart disease, drug allergies, lung disease, seizures, drug allergies, consumption of MAOIs and TCAs, increased ICP, severe kidney disease, hypothyroidism, and no addiction. Shivering was graded as following: 0= no shivering; 1= Peripheral cyanosis or peripheral vasoconstriction; 2= Visible muscular activity only in one muscle group; 3= Visible muscular activity in more than one muscle group; 4= Gross muscular activity in the entire body.

During the recovery, the patients were covered with a blanket for 3 minutes and the body temperature was raised by warming the skin surface using Warm Touch device. If they did not succeed in controlling their shivering and had score >2 after warming, they were injected with 25 mg of pethidine or 8 mg of ondansetron, and their shivering scores were recorded every 1 to 10 minutes by an anesthesia assistant who was unaware of the type of injected drug. Finally, the time when shivering score become zero and the mean score of shivering in each group in different minutes were compared. At the end, out of 96 selected patients, 27 were assigned into the meperidine group and 29 to the ondansetron group (Figure 1).

Results

Mean age, gender, anesthesia class (ASA) and fluid intake during anesthesia did not show a statistically significant difference between the two groups (Table 1).

The mean time that the shivering score reached zero in all patients who were completely treated before the 10th minute was 7 in the meperidine group and happened earlier than in the ondansetron group, and the difference between them was significantly different (Table 4).

16 cases in the ondansetron group and 10 in the meperidine group did not reach the zero score in the 10th minute and the drug needed to be re-injected to control shivering. Figure 2, which compares the mean shivering scores between the two groups, indicates that meperidine is the faster-acting drug in complete control of shivering and bringing the score down to zero.

Discussion

Drugs of 5-hydroxytryptamine receptor antagonists are used to prevent and treat nausea and vomiting, but they have also been suggested to treat shivering [2]. Piper et al. found that clonidine was more effective than dolasetron in preventing shivering after abdominal and urologic surgery [2], while the 8 mg dose of ondansetron used in Powell and Buggy’s study, which was injected before anesthesia in similar patients, was more effective in reducing the prevalence of shivering after anesthesia than the 4 mg dose of this drug and placebo. In Kelsaka et al.’s study, ondansetron and meperidine reduced shivering after spinal anesthesia compared to saline, and maintained the central body temperature. In another studies, granisetron was not effective in preventing shivering after spinal anesthesia in urological patients compared to ketamine [6], and ondansetron did not reduce the severity and prevalence of shivering in women candidates for cesarean section after concomitant epidural and spinal anesthesia [7]. 

In Entezari Asl et al.’s study [8], ondansetron and meperidine were significantly more effective in preventing shivering after general anesthesia in gynecological surgery than normal saline. Findings of Lin et al.’s study on the prevalence of shivering after caudal anesthesia in children [9], Nallam et al.’s study on shivering after spinal anesthesia during cesarean section [10], and Shakya et al.’s study [11] in comparing ketamine and ondansetron, all reported the successful effect of ondansetron in preventing shivering. Granisetron, like meperidine, has also been reported to be effective in preventing shivering after general anesthesia in laparoscopic surgery [12]. In the field of ondansetron injection for the treatment of shivering after anesthesia, Mahoori  et al. [13] found that ondansetron at a dose of 8 mg and not 4 mg was as effective as meperidine. Joshi et al. [14] reported that the effectivness and onset of action of butorphanol and tramadol was much higher than ondansetron in the treatment of shivering after spinal anesthesia. It should be noted that monitoring the patient’s body temperature does not determine the likelihood of postoperative shivering [15].

Ethical Considerations

Compliance with ethical guidelines

This research ethically approved in ethics committee of Iran University Of Medical Sciences and registered in Iranian Registry of Clinical Trials (Code: IRCT201109224969N3).

Funding

The Research Vice Chancellor of Iran University Of Medical Sciences financially supported this study.

Authors' contributions

Conceptualization, resources, project administration, funding acquisition: Alireza Pournajafian; Methodology, formal analysis, writing – original draft: Alireza Pournajafian, Mohammadreza Ghodraty; Visualization: Mohammadreza Ghodraty; Supervision: Alireza Kholdebarin; Writing – review & editing: Alireza Kholdebarin; Validation: Faranak Rokhtabnak; Investigation: Faranak Rokhtabnak, Mohammadreza Ghodraty; Data collection: Alireza Pournajafian, Alireza Kholdebarin, Faranak Rokhtabnak.

Conflicts of interest

The authors declared no conflict of interest.

Acknowledgements

The authors are grateful for the cooperation of anesthesia residents and technicians in charge of patient care in recovery room to provide the required medications and patient monitoring.

 

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