|Year : 2018 | Volume
| Issue : 1 | Page : 11-14
Prophylactic administration of ondansetron for prevention of shivering during spinal anesthesia
SP Sharma1, K Raghu1, N Nikhil2, G Rajaram3, Shishir Kumar4, Seema Singh1
1 Department Of Anaesthesiology, Command Hospital (Air Force), Bengaluru, Karnataka, India
2 Department Of Anaesthesiology, Axon Specialty Hospital, Bengaluru, Karnataka, India
3 Department Of Anaesthesiology, Air Force Hospital, Jorhat, Assam, India
4 Department Of Anaesthesiology, Military Hospital, Pithoragarh, Uttarakhand, India
|Date of Submission||28-Jan-2018|
|Date of Acceptance||26-Feb-2018|
|Date of Web Publication||22-May-2018|
Dr. K Raghu
Department of Anesthesiology, Command Hospital (Air Force), Agaram Post, Old Airport Road, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Background and Aims: Shivering is one of the causes of discomfort in patients undergoing surgeries under spinal anesthesia. A variety of drugs and physical methods are used to control shivering. Among pharmacological interventions ondansetron, a 5-hydroxytryptamine3 antagonist has been found effective in controlling shivering. The aim of this study is to evaluate the effect of prophylactic administration of ondansetron for prevention of shivering during spinal anesthesia.
Methods: A prospective, randomized, and double-blind study was conducted on 70 patients, from either gender, aged 20–60 years, of the American Society of Anesthesiologists Grade I or II, scheduled for various surgeries under spinal anesthesia. The patients were randomly divided into two groups of 35 each to receive either saline (Group S) or ondansetron 8 mg, (Group O) as slow intravenous infusion before spinal anesthesia. The primary outcome of the study was intraoperative incidence of shivering. Secondary outcomes, such as hemodynamic parameters and adverse reactions, were recorded.
Results: A total of 16 patients in Group S (45.7%) and 4 (11.3%) patients in Group O experienced shivering (P = 0.014). A total of 14 patients in Group S (40%) and five patients in Group O (14.3%) had nausea (P = 0.155). A total of 11 patients in Group S (31%) and three patients in Group O (8%) had hypotension (P = 0.168). No patients in either group experienced bradycardia.
Conclusion: Prophylactic administration of ondansetron significantly reduced shivering in patients undergoing spinal anesthesia without significant side effects.
Keywords: Ondansetron, shivering, spinal anesthesia
|How to cite this article:|
Sharma S P, Raghu K, Nikhil N, Rajaram G, Kumar S, Singh S. Prophylactic administration of ondansetron for prevention of shivering during spinal anesthesia. Indian Anaesth Forum 2018;19:11-4
|How to cite this URL:|
Sharma S P, Raghu K, Nikhil N, Rajaram G, Kumar S, Singh S. Prophylactic administration of ondansetron for prevention of shivering during spinal anesthesia. Indian Anaesth Forum [serial online] 2018 [cited 2019 Nov 21];19:11-4. Available from: http://www.theiaforum.org/text.asp?2018/19/1/11/232917
| Introduction|| |
Spinal anesthesia is a commonly used technique in both elective and emergency surgeries. Shivering is one of the most commonly encountered problems during perioperative period. It is reported in 40%–50% of the patients undergoing surgical operation under spinal anesthesia.
Etiology of shivering is not clearly understood. Various hypotheses have been proposed to explain its occurrence; these include modulation of thermoregulatory threshold, reduction in core body temperature, and changes in body heat distribution.
Shivering is very unpleasant and physiologically stressful for patients. It increases oxygen consumption by 200%–500% and increases carbon dioxide production which may lead to problems in patients with existing intrapulmonary shunts, fixed cardiac output, or limited respiratory reserve. It also increases intraocular pressure, intracranial pressure, and interferes with monitoring such as pulse oximetry, electrocardiogram, and noninvasive blood pressure measurement. Furthermore, it interferes with surgery and causes stretch on suture lines.,
There are several methods available to decrease the incidence of shivering. These include pharmacological and nonpharmacological methods. Non-pharmacological methods includes specialized equipments which works by supplying heat there by prevents development of shivering. These instruments are expensive and not practical in all settings. Pharmacological methods include drugs such as pethidine, ketamine, tramadol, clonidine, and ondansetron. Ondansetron, a 5-hydroxytryptamine3 (5-HT3) antagonist, is a widely used antiemetic during surgery. Some studies showed its antishivering effect following both general and neuraxial anesthesia.
The aim of this prospective study is to evaluate the efficacy of prophylactic administration of ondansetron in prevention of postspinal shivering.
| Methods|| |
This was a prospective, randomized, and double-blind study undertaken at a tertiary care center during the period from June 2017 to October 2017, after taking approval from our Institutional Ethical Committee. The study involved 70 patients from either gender, aged 20–50 years, of the American Society of Anesthesiologists (ASA) Grade I or II, scheduled for various elective surgeries under spinal anesthesia. Patients with known hypersensitivity to ondansetron, cardiovascular, renal, hepatic diseases, and thyroid disease were excluded from the study. All patients were visited on the day before the surgery and explained in detail about the anesthetic procedure and written informed consent was obtained. Patients were kept nil orally from 12 O'clock mid night before the day of surgery.
The selected patients were randomly divided into two groups using computer-generated random numbers. Group S received 100 ml of saline and Group O received ondansetron 8 mg in 100 ml of saline as slow intravenous (IV) infusion over 10 min before spinal anesthesia. The study drugs were given by the investigator who was not involved in the study; hence, the study was double blinded. All the patients were preloaded with 500 ml of lactated Ringer's solution. Patients' peripheral oxygen saturation, blood pressure (systolic, diastolic, and mean arterial pressure), and electrocardiogram were monitored. Basal values were recorded. Intraoperatively, temperature monitored using the temperature probe placed in axilla. The patients were placed in the sitting position, and dural puncture was performed at L3–L4 inter space. A volume of 2–3 ml of hyperbaric bupivacaine 0.5% was injected intrathecally. The volume of the local anesthetic and use of vasopressors was determined by the attending anesthesiologists, which was not affected by inclusion in the study. A blanket was used to cover the chest and upper limb of the patients. All the preloading fluids and drugs were given at room temperature. Ambient temperature of operation theater was maintained between 23°C and 25°C.
During surgery, shivering score was recorded at 5 min interval. Shivering was graded using a four-point scale as per Wrench: Grade 0: no shivering, Grade 1: one of the following: piloerection, peripheral vasoconstriction, and peripheral cyanosis but without muscle activity, Grade 2: muscular activity confined to one muscle group, Grade 3: shivering involving more than one muscle group, and Grade 4: gross muscle activity involving whole body.
Attending anesthesiologist monitored the appearance of shivering from the time of administration of spinal. If the shivering score was three or four, the treatment was considered ineffective, and 0.5 mg/kg of pethidine was given as rescue agent.
Patients' vital parameters were monitored throughout the procedure. Patients were assessed for feeling of nausea, dizziness, and observed for vomiting. Hypotension (systolic blood pressure <100 mmHg or fall >20% baseline values) was treated with injection ephedrine 6 mg IV, up to a maximum of 30 mg, heart rate <50 bpm was considered as bradycardia and treated with injection atropine 0.6 mg IV.
Sample size estimation was based on pilot study. The incidence of shivering in ondansetron group was 15% and 50% in saline group. Using this incidence of shivering, a power calculation showed a sample size of 35 in each group with α of 0.05 and a β of 0.9. Student's t-test (two tailed, independent) has been used to find the significance of study parameters on continuous scale between two groups. Chi-square test has been used to find the significance of study parameters on categorical scale between two or more groups. P < 0.05 was considered statistically significant.
| Results|| |
A total of 70 patients were enrolled in this study, 35 in saline group and 35 in ondansetron group [Figure 1]. The two groups were similar with respect to age, gender, weight, height, and ASA Grade [Table 1]. There was no statistical difference between two groups in pulse rate, systolic blood pressure, diastolic blood pressure, mean blood pressure, temperature, and duration of surgery. About 16 (45.7%) patients in Group S and 4 (11.3%) patients in Group O experienced shivering (P = 0.014) [Table 2] and [Table 3]. Nearly 14 (40%) patients in Group O and 5 (14.3%) patients in Group O experienced nausea (P = 0.155). About 11 (31%) patients in Group S and 3 (8%) patients in Group O experienced hypotension (P = 0.168). No patients in either group had bradycardia [Table 4].
| Discussion|| |
Shivering is one of the common problems encountered in perioperative period. It is encountered both after regional and general anesthesia. Around 40%–50% patients undergoing spinal anesthesia develop shivering.
The mechanism of development of shivering is not clearly known. Several hypotheses have been put forward which include cessation of sensation to the central thermoregulatory system, decrease in core body temperature secondary to sympathetic block, increased cutaneous blood flow which leads to increased heat loss, cold temperature of operation theater, and rapid infusion of cold IV fluids.,
Neurotransmitter pathways involved in shivering are complex and still poorly understood, which include opioids, α-2 adrenergic, serotonergic, and anticholinergic receptors. Hence, drugs acting on these receptors are utilized in the treatment of shivering.
Serotonin is a biologic amine found in brain and spinal cord. Many studies found out that it plays an important role in the pathogenesis of shivering., Serotonin antagonism seems to lower the human thermal set range, thereby reducing metabolic cold defenses and discomfort associated with hypothermia.
Ondansetron, a 5-HT3 antagonist, is a widely used antiemetic during surgery. Some studies showed its antishivering effect following both general and neuraxial anesthesia. The mechanism of action of ondansetron as antishivering is not clear, and it is proposed to act centrally by inhibition of serotonin uptake.
In our study, we evaluated the efficacy of ondansetron in prevention of postspinal shivering. We used 8 mg of ondansetron slow IV infusion. The selection of dose was based on the previous studies.
From our study, we found out that the incidence of shivering in ondansetron was 11.3%. The complications were found to be higher in saline group compared to ondansetron group. The incidence of nausea in saline group was found to be 40% and was higher when compared to ondansetron group. Similarly, the incidence of hypotension was more in saline group when compared to ondansetron group.
Nallam et al. studied the efficacy of IV ondensetron for prevention of postspinal shivering during lower segment cesarean section. The incidence of shivering was 10% in ondansetron group and 42.5% in saline group which are comparable to our study. In their study, 5% patients in ondansetron group had nausea when compared to 47.5% patient in saline group.
Powell and Buggy  conducted the study using two doses of ondansetron (4 mg vs. 8 mg) and placebo group for prevention of shivering. They found out that incidence of shivering was 15% in group which used 8 mg, 33% in group which used 4 mg, and 57% in saline group. The results in 8 mg group and placebo group are comparable to our study.
Kelsaka et al. studied the effect of ondansetron in preventing shivering using 8 mg of ondansetron. They found that the incidence of shivering was 8%. In the present study, the incidence of shivering was 10%.
The limitation of study was that core body temperature was not measured. However, both groups were exposed to the similar environment and statistically similar regarding patient characteristics and duration of surgery.
| Conclusion|| |
Prophylactic administration of 8 mg ondansetron significantly reduced the incidence of post spinal shivering and is also effective against nausea and vomiting without any major adverse effect.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
De Witte J, Sessler DI. Perioperative shivering: Physiology and pharmacology. Anesthesiology 2002;96:467-84.
Alfonsi P. Postanaesthetic shivering: Epidemiology, pathophysiology, and approaches to prevention and management. Drugs 2001;61:2193-205.
Katyal S, Tewari A. Shivering: Anesthetic considerations. J Anaesth Clin Pharmacol 2002;18:363-76.
Kranke P, Eberhart LH, Roewer N, Tramèr MR. Pharmacological treatment of postoperative shivering: A quantitative systematic review of randomized controlled trials. Anesth Analg 2002;94:453-60.
Bhattacharya PK, Bhattacharya L, Jain RK, Agarwal RC. Post anaesthesia shivering (PAS): A review. Indian J Anaesth 2003;47:88-93. [Full text]
Park SM, Mangat HS, Berger K, Rosengart AJ. Efficacy spectrum of antishivering medications: Meta-analysis of randomized controlled trials. Crit Care Med 2012;40:3070-82.
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.
] [Full text]
Wrench IJ, Singh P, Dennis AR, Mahajan RP, Crossley AW. The minimum effective doses of pethidine and doxapram in the treatment of post-anaesthetic shivering. Anaesthesia 1997;52:32-6.
Chan AM, Ng KF, Tong EW, Jan GS. Control of shivering under regional anesthesia in obstetric patients with tramadol. Can J Anaesth 1999;46:253-8.
Chaturvedi S, Domkondwar G. Control of shivering under regional anaesthesia using tramadol. Asian Arch Anaesthesiol Resusc 2002;57:491-6.
Tie HT, Su GZ, He K, Liang SR, Yuan HW, Mou JH, et al.
Efficacy and safety of ondansetron in preventing postanesthesia shivering: A meta-analysis of randomized controlled trials. BMC Anesthesiol 2014;14:12.
Mohammadi SS, Jabbarzadeh S, Movafegh A. Efficacy of granisetron on prevention of shivering, nausea and vomiting during cesarean delivery under spinal anesthesia. J Obstet Anaesth Crit Care 2015;5:22-6. [Full text]
Nallam SR, Cherukuru K, Sateesh G. Efficacy of intravenous ondansetron for prevention of postspinal shivering during lower segment cesarean section: A double-blinded randomized trial. Anesth Essays Res 2017;11:508-13.
] [Full text]
Powell RM, Buggy DJ. Ondansetron given before induction of anesthesia reduces shivering after general anesthesia. Anesth Analg 2000;90:1423-7.
Kelsaka E, Baris S, Karakaya D, Sarihasan B. Comparison of ondansetron and meperidine for prevention of shivering in patients undergoing spinal anesthesia. Reg Anesth Pain Med 2006;31:40-5.
[Table 1], [Table 2], [Table 3], [Table 4]