Risk factors for shivering during caesarean section under spinal anaesthesia. A prospective observational study

A Nonrandomized Comparative Study of the Warming Effects of Conductive-Polymer Heating Devices in Patients Undergoing Cesarean Delivery With Spinal Anesthesia

Maintaining normothermia during surgery is crucial to prevent perioperative hypothermia. This nonrandomized study of 70 patients undergoing cesarean delivery with spinal anesthesia compared the effectiveness of conductive-polymer heating devices (CPHDs) in maintaining temperatures and enhancing thermal comfort. Core and peripheral temperatures were recorded, and thermal comfort was assessed. Patients who were warmed with a CPHD blanket and those warmed with a CPHD blanket and a CPHD mattress reported significantly higher thermal comfort and had higher core temperatures (P < .01) than those warmed only by a CPHD mattress. Further, higher peripheral temperatures were achieved in patients warmed with a CPHD blanket or with both a CPHD mattress and a CPHD blanket when compared to those warmed by a CPHD mattress alone (P = .03). Blankets and combination warming methods are more effective than mattresses in maintaining temperatures and enhancing thermal comfort in patients undergoing cesarean delivery with spinal anesthesia.

Prophylactic ondansetron for preventing intraoperative shivering, nausea and vomiting during spinal anesthesia for cesarean section: a randomized controlled trial

Background

Shivering, nausea and vomiting are common complications in cesarean section during neuraxial anesthesia. The aim of this study was to investigate the effects of prophylactic use of ondansetron on intraoperative shivering, nausea and vomiting in women undergoing cesarean section.

Methods

A total of 80 full-term parturients were randomly divided into the ondansetron group and the control group. The ondansetron group received 0.075 mg/kg of ondansetron 15 min before anesthesia, the control group were given the same volume of saline solution. The incidence of shivering, nausea and vomiting was noted. The occurrence and severity of shivering and other outcomes, such as hypotension, bradycardia and dizziness were recorded during the surgery. Umbilical arterial blood was analyzed, and the neonatal Apgar scores were assessed.

Results

The incidence of grade ≥1 shivering was lower in ondansetron group. The incidence of shivering, nausea and vomiting was significantly lower in ondansetron group than the control group (2.5% vs. 22.3%, P = 0.007, 2.5% vs. 40%, P = 0.001, respectively). No significant differences were observed in the incidence of hypotension, bradycardia, headache and dizziness between the 2 groups (P > 0.05). The umbilical artery pH and neonatal Apgar score were similar between the 2 groups (P > 0.05).

Conclusion

Prophylactic use of ondansetron could prevent intra-operative shivering and reduce the incidence of nausea and vomiting in cesarean section under spinal anesthesia without increasing the incidence of maternal and infant adverse events.

Clinical Trial Registration

https://www.chictr.org.cn, identifier ChiCTR2100042453.

Epidural ropivacaine versus bupivacaine for cesarean sections: a system review and meta-analysis

INTRODUCTION

It is still no consensus on the use of ropivacaine or bupivacaine in epidural anesthesia for cesarean section (CS), because their anesthetic potency and relative complications remains controversial. This system review and meta-analysis aimed to compare the efficacy of epidural ropivacaine and bupivacaine for elective CSs and investigate relative complications for parturients and neonates.

METHODS

We searched PubMed, MEDLINE, Embase, Cochrane Library, Science-Direct, and Google Scholar to June 30, 2023 for randomized controlled trials (RCTs), which compared epidural ropivacaine with bupivacaine for elective CSs. The success rate of epidural anesthesia (EA) was primary outcome. The secondary outcomes included onset times of sensory block, maternal side effects, neonatal Apgar scores and umbilical artery pH.

RESULTS

We analyzed 8 RCTs with 532 parturients. 0.75% ropivacaine is associated with a shorter onset time of sensory block than 0.5% bupivacaine (SMD = -0.43, 95% CI: -0.70 to -0.17; p = .001). 0.5% ropivacaine resulted in a reduced nausea than 0.5% bupivacaine (RR = 0.49, 95% CI: 0.28 to 0.83; p = .008). In addition, there were no significant difference between ropivacaine and bupivacaine groups in terms of success rate of epidural anesthesia, maternal side effects (hypotension, bradycardia, shivering), and neonatal Apgar scores and umbilical artery pH.

CONCLUSIONS

The findings suggest that there were no significant difference between epidural ropivacaine and bupivacaine for elective CSs in terms of the success rate (85.9% vs. 83.5), maternal side effects (hypotension, bradycardia, shivering), and neonatal Apgar scores and umbilical artery pH. But compared with 0.5% bupivacaine, epidural 0.75% ropivacaine was mildly effective for reducing onset time of sensory block and 0.5% ropivacaine reduced the incidence of maternal nausea.

The impact of magnesium on shivering incidence in cardiac surgery patients: A systematic review

Background and objective

This scientific review involves a sequential analysis of randomized trial research focused on the incidence of shivering in patients undergoing cardiac surgery. The study conducted a comprehensive search of different databases, up to the end of 2020. Only randomized trials comparing magnesium administration with either placebo or no treatment in patients expected to experience shivering were included. The primary objective was to evaluate shivering occurrence, distinguishing between patients receiving general anesthesia and those not. Secondary outcomes included serum magnesium concentrations, intubation time, post-anesthesia care unit stay, hospitalization duration, and side effects. Data collection included patient demographics and various factors related to magnesium administration.

Material and methods

This scientific review analyzed 64 clinical trials meeting inclusion criteria, encompassing a total of 4303 patients. Magnesium was administered via different routes, primarily intravenous, epidural, and intraperitoneal, and compared against placebo or control. Data included demographics, magnesium dosage, administration method, and outcomes. Heterogeneity was assessed using the I2 statistic. Some studies were excluded due to unavailability of data or non-responsiveness from authors.

Result

and discussion: Out of 2546 initially identified articles, 64 trials were selected for analysis. IV magnesium effectively reduced shivering, with epidural and intraperitoneal routes showing even greater efficacy. IV magnesium demonstrated cost-effectiveness and a favorable safety profile, not increasing adverse effects. The exact dose-response relationship of magnesium remains unclear. The results also indicated no significant impact on sedation, extubation time, or gastrointestinal distress. However, further research is needed to determine the optimal magnesium dose and to explore its potential effects on blood pressure and heart rate, particularly regarding pruritus prevention.

Conclusion

This study highlights the efficacy of intravenous (IV) magnesium in preventing shivering after cardiac surgery. Both epidural and intraperitoneal routes have shown promising results. The safety profile of magnesium administration appears favorable, as it reduces the incidence of shivering without significantly increasing costs. However, further investigation is required to establish the ideal magnesium dosage and explore its potential effects on blood pressure, heart rate, and pruritus prevention, especially in various patient groups.

Maternal hypothermia during elective caesarean delivery: A prospective observational study

BACKGROUND

Patients undergoing caesarean delivery are at risk of developing unintended perioperative hypothermia, defined as a core temperature <36.0°C. Most previous studies of core temperature in caesarean delivery patients have not been conducted with accurate measurements for the complete perioperative period. Therefore, we conducted a prospective observational study to identify the incidence and duration of pre- and post-operative maternal hypothermia with a high accuracy continuous temperature monitoring system.

METHODS

Women ≥18 years old presenting for elective caesarean delivery under spinal anaesthesia were invited to participate in the study. The primary outcomes were the incidence and duration of perioperative maternal hypothermia (<36.0°C). Maternal core temperatures were measured with the non-invasive zero-heat-flux thermometer (Bair Hugger Temperature Monitoring System, 3M) throughout the perioperative course.

RESULTS

A total of 40 participants were recruited to the study. The incidence of perioperative hypothermia was 32.5%, with a duration of 77 ± 40 min (mean ± standard deviation). The hypothermic patients had similar core temperature as the normothermic patients at baseline preoperatively, but significantly lower temperature at operating room arrival and during the remaining study period. Forty percent of all patients reported thermal discomfort and felt cold on admission to post anaesthesia care unit, whereas 33% had shivering. Neither thermal discomfort nor shivering were associated with hypothermia.

CONCLUSION

In the present study almost a third of the women undergoing elective caesarean delivery developed perioperative hypothermia with a core temperature <36.0°C. The mean duration of maternal hypothermia was 77 min, lasting well into the postoperative period for many patients. These data should remind healthcare professionals of the importance of measuring core temperature in all phases of the perioperative setting and to consider optimal warming measures to avoid and treat hypothermia.

Effect of pre-operative patient anxiety on post-spinal shivering during elective cesarean delivery: a prospective observational study

BACKGROUND

Shivering after spinal anesthesia is common during cesarean delivery (CD), and is thought to be primarily a thermoregulatory response. By inducing autonomic changes, pre-operative anxiety could alter the functioning of the thermoregulatory center, hence modifying the incidence and severity of obstetric post-spinal shivering. This prospective observational study was conducted to explore the relationship between pre-operative anxiety and obstetric post-spinal shivering.

METHODS

Patients ≥18 years of age and scheduled for elective CD under spinal anesthesia were enrolled. Pre-operative anxiety was measured on the day of surgery using a visual analogue scale (VAS) and the Amsterdam Preoperative Anxiety and Information Scale (APAIS), and was correlated with the incidence of post-spinal shivering. Other possible risk factors for post-spinal shivering were explored using univariate and multivariate logistic regression models.

RESULTS

Among the 150 participants, 46 (31%) experienced post-spinal shivering. The relative risk of intra-operative shivering in those with high APAIS pre-operative anxiety was 2.76 (95% CI 1.55 to 4.90; P = 0.0005). Younger patient age (aOR 0.91, 95% CI 0.83 to 0.98; P = 0.02), higher APAIS anxiety score (aOR 1.21, 95% CI 1.06 to 1.37; P = 0.005), higher VAS anxiety score (aOR 1.48, 95% CI 1.24 to 1.78; P < 0.001) were independent risk factors for post-spinal shivering.

CONCLUSIONS

High pre-operative anxiety and younger patient age were independent risk factors for post-spinal shivering during elective CD. Targeted interventions to reduce pre-operative patient anxiety might have a positive impact in decreasing the incidence of intra-operative post-spinal shivering in this patient population.

Risk factors associated with intraoperative shivering during caesarean section: a prospective nested case-control study

BACKGROUND

To study the incidence and risk factors of shivering in pregnant women during cesarean section.

METHODS

We performed a prospective nested case-control study involving parturients scheduled for cesarean sections between July 2018 and May 2021. The overall incidence of intraoperative shivering and its potential risk factors were investigated. The potential risk factors evaluated were pain, anxiety, emergency surgery, transfer from the delivery room, epidural labor analgesia, membrane rupture, labor, and the timing of the surgery. Shivering and body temperature at different time points during the cesarean section were also recorded. The selected seven time points were: entering the operating room, post-anesthesia, post-disinfection, post-delivery, post-oxytocin, post additional hysterotonics, and before leaving the operating room.

RESULTS

We analyzed 212 cesarean section parturients. The overall incidence of shivering was 89 (42.0%). Multivariate logistic regression showed that anxiety, emergency delivery, and transfer from the delivery room to the operating room increased the overall shivering incidence (odds ratio = 1.77, 2.90, and 3.83, respectively). The peak shivering incidence occurred after skin disinfection (63, 29.7%), and the lowest body temperature occurred after oxytocin treatment (36.24 ± 0.30 °C). Stratified analysis of surgery origin showed that emergency delivery was a risk factor for shivering (odds ratio = 2.99) in women transferred from the obstetric ward to the operating room.

CONCLUSION

Shivering occurred frequently during cesarean sections, with the peak incidence occurring after skin disinfection. Anxiety, emergency delivery, and transfer from the delivery room to the operating room increased the risk of shivering development during cesarean sections.

TRIAL REGISTRATION

The study protocol was registered online at China Clinical Registration Center (registration number: ChiCTR-ROC-17010532, Registered on 29 January 2017).

Comparing the Effects of Low Dose of Ketamine, Tramadol, and Ondansetron in Prevention of Post Spinal Anesthesia Shivering in Cesarean Section

Background

Shivering frequently occurs in cesarean section (CS) under spinal anesthesia (SA), resulting in several complications. To date, pethidine has been considered as the gold standard for post-SA shivering control, but it is contraindicated in breastfeeding women.

Methods

This randomized, double-blind study was conducted at Alzahra hospital in Guilan, Iran, From January 2019 to November 2020. A total of 508 eligible term parturient women were enrolled and randomly divided into four groups of low dose ketamine (K), tramadol (T), ondansetron (O), and placebo (P). The incidence and severity of shivering and patients' complications were recorded and compared among the groups.

Results

The patients were homogenous in terms of demographic variables. Shivering was witnessed in 68 (53.5%), 26 (20.5%), 75 (59.1%), and 82 (64.6%) patients in K, T, O, and P groups, respectively (P = 0.0001). Regarding shivering severity, there was a significant difference among the four groups (P = 0.0001). In addition, a significant difference was seen regarding Apgar scores at the first minute, but not at the fifth minute (P = 0.168).

Conclusions

Considering the high incidence of shivering in placebo group, prophylactic intervention in CS under SA seems to be necessary. Among the studied drugs, tramadol was the most effective one, followed by a low dose of ketamine and ondansetron.

The relationship between core temperature and perioperative shivering during caesarean section under intrathecal anesthesia with bupivacaine and ropivacaine: a randomized controlled study

Purpose

To assess the incidence rate of perioperative shivering for cesarean section and explore the associations between the occurrence of shivering and hypothermia, core temperature change, local anesthetic.

Methods

This is a prospective, randomized, controlled, double-blinded study of 100 patients consenting for caesarean section under intrathecal anesthesia. Parturients with ASA I or II accepted elective caesarean section with combined spinal-epidural anesthesia (SA). 2–2.5 ml of 0.5% bupivacaine or 0.5% ropivacaine was intrathecally injected in group B and group R, respectively.

Results

The intraoperative shivering incidence in group B was significantly higher than that in group R (66.7 vs. 20.5%, Pvalue < 0.001), and shivering intensity in group B was significantly greater than group R (score: 1.4 vs. 0.3, Pvalue < 0.001). The core temperature in both groups gradually decreased with the time after SA. Hypothermia (core temperature < 36.0 ℃) 5–30 min after SA was not associated with shivering. However, changes of temperature at 25 and 30 min after SA, and bupivacaine were statistically associated with shivering, with the odds of 10.77 (95% CI: 1.36–85.21, P value = 0.02), 8.88 (95% CI: 1.29–60.97, P value = 0.03), and 7.78 (95% CI: 2.94–20.59, P value < 0.01), respectively.

Conclusions

In our study, for cesarean section, the occurrence of shivering was associated with the local anesthetics and the change of core temperature after SA, while not the hypothermia.

A multicenter survey of perioperative anxiety in China: Pre- and postoperative associations

OBJECTIVES

To describe patient characteristics associated with preoperative anxiety and subsequently assess the relationship between preoperative anxiety and postoperative anxiety, pain, sleep quality, nausea and vomiting.

METHODS

The study collected data from patients undergoing elective operation from 12 hospitals in China. The State-Trait Anxiety Inventory (STAI) and the Athens Insomnia Scale (AIS) were used to assess anxiety and sleep quality before surgery. Evaluations of anxiety, pain, sleep quality, nausea and vomiting were quantified using the Visual Analogue Scale on postoperative days 1 and 2.

RESULTS

Data from 997 patients were analyzed. Preoperatively, 258 (25.9%) patients had high anxiety (STAI-State>44). Multivariate analyses showed a significant relationship between high anxiety and female gender (OR: 1.66, 95% CI: 1.08-2.57, p = 0.02), highly invasive surgery (OR: 2.29, 95% CI: 1.29-4.06, p = 0.005), higher trait anxiety (OR: 1.24, 95% CI: 1.20-1.28, p < 0.001) and insomnia (AIS ≥ 6, OR: 1.79, 95% CI: 1.17-2.76, p = 0.008). Preoperative anxiety demonstrated a negative correlation with postoperative anxiety following highly invasive surgery; this became a positive relationship following less invasive surgery. Preoperative anxiety was also positively related to postoperative pain and poor sleep quality. The correlation between preoperative anxiety and postoperative nausea and vomiting was not statistically significant.

CONCLUSION

Female gender, highly invasive surgery, higher trait anxiety and insomnia are independent risk factors for high preoperative anxiety. Surgical invasiveness influences association between pre- and postoperative anxiety. Higher preoperative anxiety is related to poorer sleep quality and more severe pain postoperatively.