|Year : 2016 | Volume
| Issue : 2 | Page : 81-85
Prophylactic intravenous paracetamol for prevention of shivering after general anesthesia in elective cesarean section
Ahmadreza S Gholami1, Mehdi Hadavi2
1 Department of Anesthesiology, Besat Nahaja General Hospital, Tehran, Iran
2 Aja University of Medical Sciences, Besat Nahaja General Hospital, Tehran, Iran
|Date of Web Publication||7-Oct-2016|
Ahmadreza S Gholami
Department of Anesthesiology, Besat Nahaja General Hospital, Tehran
Source of Support: None, Conflict of Interest: None
Background: Postoperative shivering is an important common complication after general anesthesia. This may lead to dissatisfaction and a sense of discomfort, especially in parturients undergoing cesarean section. In addition to warming, many drugs have been investigated for prevention of shivering. The aim of this study was to evaluate the efficacy of intravenous paracetamol for prevention of shivering after general anesthesia in cesarean section.
Materials and Methods: In this prospective randomized double-blind controlled clinical trial, 110 pregnant women, physical Status I or II, based on the classification of American Society of Anesthesiologists (ASA), aged 18–40 years, who were scheduled for elective cesarean section under general anesthesia were included in the study. They were randomly divided into two groups of 55 each. One group received 100 ml normal saline, and another group received 1 g of paracetamol in 100 ml normal saline intravenously, 15 min after the delivery of the baby. The anesthesia technique was similar in both the groups. Tympanic membrane temperature was measured before and after the induction of anesthesia and every 15 min till the end of recovery from anesthesia. Postanesthetic shivering was graded on a scale of 0 to 4; if the score was more than 2, it was treated with 25 mg pethedine. Vital signs and side effects were recorded during the surgery and recovery period.
Results: There were no significant differences between the two groups regarding age, weight, height, and duration of surgery (P > 0.05). Shivering was seen in 5 parturients (9.1%) in paracetamol group (group A) and 28 parturients (50.9%) in the saline group (group N). On a scale of 0 to 4, shivering was of lower intensity in paracetamol group compared to the saline group (P < 0.05). There was a fall in core temperature in both the groups after induction of anesthesia, which was statistically similar (P > 0.05). There was no difference in the incidence of hypotension, nausea, and vomiting among the two groups (P > 0.05).
Conclusion: The prophylactic use of intravenous paracetamol during surgery is effective for the prevention of postoperative shivering.
Keywords: General anesthesia, paracetamol, shivering
|How to cite this article:|
Gholami AS, Hadavi M. Prophylactic intravenous paracetamol for prevention of shivering after general anesthesia in elective cesarean section. J Obstet Anaesth Crit Care 2016;6:81-5
|How to cite this URL:|
Gholami AS, Hadavi M. Prophylactic intravenous paracetamol for prevention of shivering after general anesthesia in elective cesarean section. J Obstet Anaesth Crit Care [serial online] 2016 [cited 2017 May 24];6:81-5. Available from: http://www.joacc.com/text.asp?2016/6/2/81/191601
| Introduction|| |
Postanesthetic shivering is one of the most common complications in the recovery period after general anesthesia. It can occur in 5–65% of patients after general anesthesia. Shivering has many side effects such as increase in oxygen consumption, blood pressure, and carbon dioxide production, distressing patients with coronary artery disease; it can also cause pain and discomfort in patients. In general anesthesia, vasodilation combined with a redistribution of body heat from core tissues to peripherals causes heat lost.
There are two ways to reduce shivering, including forced warming of the patient  and use of pharmaceutical agents. Many agents have been evaluated for the prevention or treatment of shivering, including intravenous opioids, physostigmine, dexmedetomidine, ketamine, ondansetron, granisetron, clonidine, tramadol, dexamethasone, doxapram, and ephedrine.,, Pethidine is one of the frequent choices to prevent postoperative shivering. An important dangerous complication of pethidine is respiratory depression, especially in the presence of previously administered anesthetic drugs. Furthermore, nausea and vomiting are also an important side effect of opioids., Intravenous acetaminophen (paracetamol) is an effective and safe drug for managing mild to moderate pain. In contrast to opioids, it does not cause sedation, respiratory depression, constipation, or vomiting. Shivering, is a thermoregulatory defense mechanism. Antishivering drugs decrease the shivering threshold., Paracetamol acts through a centrally mediated prostaglandin inhibition to decrease the hypothalamic temperature set point.,,, Rectal administration of acetaminophen has been shown to be effective for prevention of shivering in the therapeutic hypothermia; thus, paracetamol may be effective in preventing shivering after general anesthesia.
The aim of this study was to assess the efficacy of prophylactic paracetamol on postanesthetic shivering. To the best of our knowledge, there is no study regarding intravenous paracetamol as a prophylactic agent against postoperative shivering.
| Materials and Methods|| |
The current study was a prospective randomized double blind trial. The sample size of the study was calculated based on a type I error of 0.05, a study power of 80, and a minimum difference of 25% in the prevalence of postanesthetic shivering between the two groups. Thus, 110 parturients aged 18–40 years, ASA status I or II undergoing elective cesarean section were selected for the study. The ethical approval was obtained from the ethical committee of the University of Medical Sciences. A written informed consent was obtained from all the participants. The parturients were randomly to two equal groups (55 participants in each group). The exclusion criteria included history of allergy to paracetamol, cardiopulmonary disease, hypertension, diabetes, renal disease (creatinine more than 1.5), chronic lung disease, liver disease, history of alcohol abuse, and body temperature more than 38°C or less than 36°C. The parturients randomly received 100 ml normal saline (N group, n = 55), or 1 gram paracetamol in 100 ml normal saline (A group, n = 55) intravenously, 15 min after the delivery of the baby.
The anesthesia technique was similar in both groups. During the surgery, the heart rate, blood pressure, oxygen saturation, and end tidal carbon dioxide were monitored. Core temperature was measured before and after induction of anesthesia and every 15 min till the end of recovery from anesthesia. Operation room temperature was maintained at 22–24°C. Anesthesia was induced with thiopental sodium 5 mg/kg and succinylcholine 1.5 mg/kg was used for rapid sequence orotracheal intubation. Anesthesia was maintained with 0.8 MAC isoflurane in 50% oxygen and 50% nitrous oxide.
Cold fluid infusion was avoided. Muscle relaxation for surgery was maintained with 0.5 mg/kg atracurium. After neonate delivery, 2 µg/kg fentanyl, 0.05 mg/kg midazolam, and oxytocin 30 IU were infused. Each woman received 15 ml/kg intravenous warm crystalloid during surgery. Neuromuscular blockade was reversed with neostigmine 0.04 mg/kg and atropine 0.02 mg/kg at the end of operation. The patients were extubated when they had a good respiratory pattern and were awake enough to maintain their airway. Duration of the surgery was recorded for each patient. In the recovery room, all parturients were observed for 30 min and they were covered with a blanket.
Patients were observed and nausea and vomiting, respiratory condition, hypotension, and shivering grade were recorded for each patient. The person doing observation in postoperative ward was blind to the group allocation.
The shivering was graded by Tsai and Chu method, from a score of 0 to 4, where 0 implies no shivering; 1 implies one or more of the following: Piloerection, peripheral, vasoconstriction, peripheral cyanosis with no other cause, but no muscle activity; 2 implies visible muscular activity confined to one muscle group; 3 implies visible muscular activity in more than one muscle group; and 4 implies gross muscular activity involving the whole body.
Shivering grade 3 or more was considered as shivering in this study and treated with 25 mg pethidine as the treatment agent. Parturients with nausea and vomiting were treated with ondansetron 4 mg.
Data analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 19.0 for windows (IBM Corporation, New York, United States). The incidence of shivering and side effects were compared using t-test and Chi-square test. The results were reported as mean ± standard deviation (SD). P value less than 0.05 was considered to be significant.
| Results|| |
There were no differences in parturient characteristics between the two groups in the baseline study [Table 1]. The number of parturients with postoperative shivering in the recovery room till 30 minutes after delivery were significantly less in group A (paracetamol) compared to group N (saline), as shown in [Table 2] (P < 0.05). Twenty-eight parturients (50.9%) shivered at grade 3 or 4 in group N, however, only 6 parturients (9.1%) reached grade 3 shivering in group A [Figure 1]. There was a fall in core temperature in both the groups after induction of anesthesia, which was statistically similar (P > 0.05) [Figure 2], [Table 3]. There were no significant differences in postoperative nausea and vomiting or hypotension between the two groups (P > 0.05). None of parturients had respiratory depression [Table 4]. None of the women in the study groups had episodes of oxygen desaturation and cardiovascular complication.
|Table 1: Demographic and surgical characteristics of parturients enrolled in the study|
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|Table 2: Number of parturients with different grades of shivering in the two groups|
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| Discussion|| |
During postanesthetic period, shivering is an important, harmful, and widespread side effect caused by general anesthesia. It can cause hypoxia, pain, and lactic acidosis. Furthermore, it may interfere with the monitoring devices. Thus, prevention of shivering is important especially in patients with cardiopulmonary disease or elderly patients.,,,
Hypothermia may cause postanesthetic shivering by change of thermoregulatory mechanism. However, a relationship has been observed between core temperature and occurrence of shivering. The result of this study showed that intravenous paracetamol was effective in preventing shivering due to general anesthesia. Age, long duration of surgery, cold temperature in the room, and cold fluids infusion, are risk factors for postoperation shivering, thus, the operation room temperature was maintained at 22–24°C and cold infusion was avoided in this study. Although many pharmacological agents have been used to treat or prevent postanesthesia shivering, the ideal treatment has not yet been found. Paracetamol is a safe and effective analgesic agent for mild to moderate pain. Intravenous infusion of acetaminophen (paracetamol) results in a rapid elevation in plasma concentration, approximately within 15–20 min after the injection, which declines after 4 h. In 2010, the Food and Drug Association (FDA) approved the use of intravenous acetaminophen for the management of pain and fever. The mechanism of intravenous acetaminophen may involve central inhibition of COX2, inhibition of NO generation via blockade of N-methyl-D-aspartate (NMDA) receptors, activation of descending serotonergic pathways, and inhibition of COX3.,,, Serotonergic pathways are part of the descending pain system, and it has been accepted that the activation of serotonergic pathways plays a key role in the analgesic effect of paracetamol.,,,, Paracetamol acts on the heat-regulatory center by inhibition of prostaglandin synthesis.,,,, Conversion of paracetamol to N-arachidonoylphenolamine (AM404), an endocannabinoid reuptake inhibitor, appears to be an important in pain control.,
Lack of adverse effects associated with other antishivering drugs is the main advantage of paracetamol., Many studies have reported adverse side effects for other antishivering medications. Benzodiazepines can cause sedation and delayed awakening. Propofol has hemodynamic side effects such as hypotension, bradycardia, and sedation. Clonidine and dexmetomidine may cause hypotension. Tramadol can decrease sweating and seizure threshold. Ketamine has psychotomimetic adverse effects such as hallucination and bad dreams.
Among these drugs, pethidine is still the best effective drug used for prevention and management of shivering, however, it can produce sedation, nausea, and vomiting or respiratory distress. Although many studies have approved the analgesic effect of intravenous paracetamol,,, the present study was the first evaluation of intravenous paracetamol for prevention of postoperative shivering.
| Conclusion|| |
This study showed the efficacy of prophylactic paracetamol on postanesthetic shivering, which can be a good agent for treatment of shivering in a recovery room to reduce the use of opioids and its related side effects such as sedation, respiratory depression, nausea, and vomiting.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Iqbal A1, Ahmed A, Rudra A, Wankhede RG, Sengupta S, Das T, et al
. Prophylactic granisetron vs pethidine for the prevention of postoperative shivering: A rondomized control trial. Indian J Anaesth 2009;53:330-4.
Asl ME, Isazadefar KH, Mohammadian A, Khoshbaten M. Ondansetron and meperidine prevent postoperative shivering after general anaesthesia. Middle East J Anaesth 2011;21:67-70.
Alfonsi P. Postanaesthetic shivering, epidemiology, pathophysiology and approaches to prevention and management. Minerva Anestesiol 2003;69:438-42.
Chung SH1, Lee BS, Yang HJ, Kweon KS, Kim HH, Song J, et al
. Effect of preoperative warming during cesarean section under spinal anesthesia. Korean J Anesthesiol 2012;62:454-60.
Abdelmageed WM, Al Taher WM. Intramuscular dexmedetomidine for prevention of shivering after general anesthesia in patients undergoing arthroscopic anterior cruciate ligament reconstruction. Ain-Shams J Anesthesiol 2014;7:156-62.
Shakya S, Chaturvedi A, Sah BP. Prophylactic low dose ketamine and ondansetron for prevention of shivering during spinal anaesthesia. J Anaesthesiol Clin Pharmacol 2010;26:465-9.
Reddy VS, Chiruvella S. Clonidine versus tramadol for post spinal shivering during cesarean section: A randomized double blind clinical study. J Obstet Anaesth Crit Care 2011;1:26.
Piper SN, Rohm KD, Malek WH, Fent MT, Sutiner SW, Boldt J. Dolasetron for preventing postanaesthetic shivering. Anesth Analg 2002;94:106-11.
EI-Deeb A, Barakat R. Could ephedrine replace meperidine for prevention of shivering in women undergoing cesarean section under spinal anesthesia? A randomized study. Egyptian J Anaesth 2012;28:237-41.
Kouchek M, Mansouri B, Mokhtari M, Goharani R, Miri MM, Sistanizad M. A comparative study of intravenous paracetamol and fentanyl for pain management in ICU. Iran J Pharm Res 2013;12:193-8.
Smith C, Coleman A, Al-Baghdadi Y, Orlewicz M. Therapeutic hypothermia in PEA cardiac arrest for global and local cerebral protection: A case report and mini-review. Romanian J Anaesth Intensive Care 2011;18:153-5.
Choi HA, Ko SB, Presciutti M, Fernandez L, Carpenter AM, Lesch C, et al
. Prevention of shivering during therapeutic temperature modulation: The Columbia anti-shivering protocol. Neurocrit Care 2011;10:9474-7.
Honasoge A, Parker B, Wesselhoff K, Lyons N, Kulstad E. First use of a new device for administration of buspirone and acetaminophen to suppress shivering during therapeutic hypothermia. Ther Hypothermia Temp Manag 2016;6:48-51.
Kasner SE, Wein T, Piriyawat P, Villar-Cordova CE, Chalela JA, Krieger DW, et al
. Acetaminophen for Altering Body Temperature in Acute Stroke: A randomized clinical trial. Stroke 2002;33:130-4.
Ayoub SS, Botting RM, Goorha S, Colville-Nash PR, Willoughby DA, Ballou LR. Acetaminophen-induced hypothermia in mice is mediated by a prostaglandin endoperoxide synthase 1 gene derived protein. Proc Nat Acad Sci U S A 2004;101:11165-9.
Tsai Ye, Chu KS. A comparison of tramadol, amitriptyline, and meperidine for postepidural anesthetic shivering in parturients. Anesth analg 2001;93:1288-92.
Kranke P, Eberhart LH, Roewer N, Tramer MR. Single dose paracetamol pharmacological interventions for the prevention of postoperative shivering: A quantitative systemic review of randomized controlled trials. Anesth Analg 2004;99:718-27.
Sagir O, Gulhas N, Yucel TA, Begee Z, Ersoy O. Control of shivering during regional anaesthesia: Prophylactic ketamine and granisetron. Acta Anaesiol Scand 2004;51:44-4.
Chan AM, Ng KF, Tong EW, Jan GS. Control of shivering under regional anaesthesia in obstetric patients with tramadol. Can J Anaesth 1999;46:253-8.
Vanderstappen I, Vandermeersch E, Vanacker B, Mattheussen M, Herijgers P, Van Aken H. The effect of prophylactic clonidine on postoperative shivering: A large prospective double blind study. Anaesthesia 1996;51:351-5.
Wininger SJ, Miller H, Minkowitz HS, Royal MA, Ang RY, Breitmeyer JB, et al
. A randomized double-blind placebo-controlled, multicenter, repeat dose study of two intravenous acetaminophen dosing regimens for the treatment of pain after abdominal laparascopic surgery. Clin Ther 2010;32:2348-69.
Vadivelu N, Mitra S, Narayan D. Recent advances in postoperative pain management. Yale J Biol Med 2010;83:11-25.
Mauger AR, Taylor L, Harding C, Wright B, Foster J, Castle PC. Acute acetaminophen (paracetamol) ingestion improves time to exhaustion during exercise in the heat. Exp Physiol 2014;99:164-71.
Mattia C, Coluzzi F. What anesthesiologists should know about paracetamol (acetaminophen). Minerva Anestesiol 2009;75:644-53.
Smith SH. Potential analgesic mechanisms of acetaminophen. Pain Physician 2009;12:269-80.
Graham GG, Scott KF. Mechanism of action of paracetamol. Am J Therapeutics 2005;12:46-55.
Roca-Vinardell A, Ortega-Alvaro A, Gilbert-Rahola J, Micò JA. The role of 5HT1A/B autoreceptors in the antinociceptive effect of systemic administration of acetaminophen. Anesthesiology 2003;98:41-7.
Bujalska M. Effects of nitric oxide synthase inhibition on antinociceptive action of different doses of acetaminophen. Polish J Pharma 2004;56:605-10.
Ottani A, Leone S, Sandrini M, Ferrari A, Bertolini A. The analgesic activity of paracetamol is prevented by the blockade of cannabinoid CB1 receptors. Eur J Pharmacol 2006;531:280-1.
Pasero C, Stannard D. The role of intravenous paracetamol in acute pain management: A case-illustrated review. Pain Manag Nurs 2012;13:107-24.
Apfel CC, Homuss C. Intravenous paracetamol reduces postoperative nausea and vomiting: A systemic review and meta-analysis. Int Assoc Study Pain 2013;154:677-89.
Arici S, Gurbet A, Türker G, Yavaşcaoğlu B, Sahin S. Preemptive analgesic effects of intravenous paracetamol in total abdominal hysterectomy. Agri 2009;21:54-61.
Alhashemi JA, Alotaibi QA, Mashaat MS, Kaid TM, Mujallid RH, Kaki AM. Intravenous acetaminophen vs oral ibuprofen in combination with PCIA after cesarean delivery. Can J Anesth 2006;53:1200-6.
Cakan T, Inan N, Culhaoglu S, Bakkal K, Başar H. Intravenous paracetamol improves the quality of postoperative analgesia but does not decrease narcotic requirements. J Neurosurg Anesthesiol 2008;20:169-73.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]