Neuraxial adjuvants for prevention of perioperative shivering during cesarean section: A network meta-analysis following the PRISMA guidelines

Abstract

BACKGROUND Perioperative shivering is clinically common during cesarean sections under neuraxial anesthesia, and several neuraxial adjuvants are reported to have preventive effects on it. However, the results of current studies are controversial and the effects of these neuraxial adjuvants remain unclear. AIM To evaluate the effects of neuraxial adjuvants on perioperative shivering during cesarean sections, thus providing an optimal choice for clinical application. METHODS A systematic review and network meta-analysis were conducted following the PRISMA (Preferred Reported Items for Systematic Review and Meta-analysis) guidelines. Analyses were performed using Review Manager 5.3 and Stata 14.0. We searched PubMed, EMBASE, Web of Science, and Cochrane Central databases for eligible clinical trials assessing the effects of neuraxial adjuvants on perioperative shivering and other adverse events during cesarean sections. Perioperative shivering was defined as the primary endpoint, and nausea, vomiting, pruritus, hypotension, and bradycardia were the secondary outcomes. RESULTS Twenty-six studies using 9 neuraxial adjuvants for obstetric anesthesia during caesarean sections were included. The results showed that, compared with placebo, pethidine, fentanyl, dexmedetomidine, and sufentanil significantly reduced the incidence of perioperative shivering. Among the four neuraxial adjuvants, pethidine was the most effective one for shivering prevention (OR = 0.15, 95%CI: 0.07-0.35, surface under the cumulative ranking curve 83.9), but with a high incidence of nausea (OR = 3.15, 95%CI: 1.04-9.57) and vomiting (OR = 3.71, 95%CI: 1.81-7.58). The efficacy of fentanyl for shivering prevention was slightly inferior to pethidine (OR = 0.20, 95%CI: 0.09-0.43), however, it significantly decreased the incidence of nausea (OR = 0.34, 95%CI: 0.15-0.79) and vomiting (OR = 0.25, 95%CI: 0.11-0.56). In addition, compared with sufentanil, fentanyl showed no impact on haemodynamic stability and the incidence of pruritus. CONCLUSION Pethidine, fentanyl, dexmedetomidine, and sufentanil appear to be effective for preventing perioperative shivering in puerperae undergoing cesarean sections. Considering the risk-benefit profiles of the included neuraxial adjuvants, fentanyl is probably the optimal choice.

Effect of intrathecal lipophilic opioids on the incidence of shivering in women undergoing cesarean delivery after spinal anesthesia: a systematic review and bayesian network meta- analysis of randomized controlled trials

“…Also, the pruritus associated with IT fentanyl and sufentanil is transient and resolves rapidly, usually without any need for treatment [ 11 , 21 ]. The results of our study are supported by similar findings, which compared nine different neuroaxial adjuvants and found fentanyl to be the optimal choice [ 38 ].…”

“…Also, the pruritus associated with IT fentanyl and sufentanil is transient and resolves rapidly, usually without any need for treatment [11,21]. The results of our study are supported by similar findings, which compared nine different neuroaxial adjuvants and found fentanyl to be the optimal choice [38]. Sufentanil is highly lipophilic with a higher affinity to opioid receptors, with a less cephalad spread and a much higher analgesic potency when compared with fentanyl or morphine [39][40][41].…”

Effect of Intrathecal Lipophilic Opioids on the Incidence of Shivering in Women Undergoing Cesarean Delivery after Spinal Anesthesia: A Systematic Review and Bayesian Network Meta- analysis of Randomized Controlled Trials.

“…11,21 The results of our study are supported by similar ndings, which compared nine different neuroaxial adjuvants and found fentanyl to be the optimal choice. 38 Sufentanil is highly lipophilic with a higher a nity to opioid receptors, with a less cephalad spread and a much higher analgesic potency when compared with fentanyl or morphine. [39][40][41] It is well accepted for use in spinal anesthesia together with local anesthetics for caesarean delivery.…”

Long-term aspirin use for primary cancer prevention: An updated systematic review and subgroup meta-analysis of 29 randomized clinical trials

“…Heterogeneity among the studies was assessed using the I-squared test. Substantial heterogeneity was indicated by I 2 > 50%, and a random-effects model was used (Review Manager version 5, Cochrane Collaboration, Copenhagen, Denmark) to estimate the summary RR and 95% CI; otherwise, a fixed-effects model was applied [26,[28][29][30][31][32][33]. If quantitative synthesis was not appropriate, a systematic narrative synthesis of the information was provided to summarize and explain the features and findings of the included RCTs [25,[34][35][36].…”