Postspinal anesthesia shivering in lower abdominal and lower limb surgeries: a randomized controlled comparison between paracetamol and dexamethasone

Abstract

Background Shivering is known to be a frequent complication in patients undergoing surgery under neuraxial anesthesia with incidence of 40–70%. Although many pharmacological agents have been used to treat or prevent postspinal anesthesia shivering (PSAS), the ideal treatment wasn’t found. This study evaluated the efficacy of paracetamol and dexamethasone to prevent PSAS in patients undergoing lower abdominal and lower limb surgeries. Methods Three hundred patients scheduled for surgeries under spinal anesthesia (SA) were allocated into three equal groups to receive a single preoperative dose of oral paracetamol 1 g (P group), dexamethasone 8 mg intravenous infusion (IVI) in 100 ml normal saline (D group) or placebo (C group), 2 h preoperatively, in a randomized, double-blind trial. The primary endpoint was the incidence of clinically significant PSAS. Secondary endpoints included shivering score, the change in hemodynamics, adverse events (e.g., nausea, vomiting and pruritis) and patients` satisfaction. Results Clinically significant PSAS was recorded as (15%) in P group, (40%) in D group and (77%) in C group (P < 0.001). The mean blood pressure values obtained over a 5-25 min observation period were significantly higher in the D group (P < 0.001). Core temperature 90 min after SA was significantly lower in the 3 groups compared to prespinal values (P < 0.001). Nausea, vomiting and pruritis were significantly higher in the C group (P < 0.001). P and D groups were superior to C group regarding the patients’ satisfaction score (P < 0.001). Conclusion Paracetamol and dexamethasone were effective in prevention of PSAS in patients undergoing lower abdominal and lower limb surgeries compared to placebo controls. Trial registration ClinicalTrials.gov Identifier: NCT03679065 / Registered 20 September 2018 - Retrospectively registered, http://www.ClinicalTrial.gov.

The Effect of Prophylactic Steroids on Shivering in Adults Undergoing Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

“…7,14,15,26,29–31,33–43,45–47 However, a power analysis was reported in only 16 studies. 7,14,15,30,31,33–36,38,40,41,43,45–47 Dexamethasone was administered intravenously in 18 studies, 7,14,26,27,29,31,32,35,37–39,41–47 and through the intrathecal route in 3 studies. 28,36,40 Hydrocortisone was administered through the intravenous route in 4 studies.…”

“…48 Another study was excluded because the authors only evaluated the severity risk and not the risk of overall shivering. 49 While 2 studies evaluated the effect of prophylactic steroids on shivering in patients undergoing cardiac surgery, 7,27 19 studies were in patients undergoing various noncardiac surgeries, 15,26,[28][29][30][31][32][33][34][35][36][37][38][39][42][43][44][45][46] and 4 studies were performed in women undergoing cesarean deliveries. 14,40,41,47 Perioperative shivering was the primary outcome in 21 studies.…”

“…7,14,15,26,[29][30][31][33][34][35][36][37][38][39][40][41][42][43][45][46][47] However, a power analysis was reported in only 16 studies. 7,14,15,30,31,[33][34][35][36]38,40,41,43,[45][46][47] Dexamethasone was administered intravenously in 18 studies, 7,14,26,27,29,31,32,35,[37][38][39][41][42][43][44]…”

“…Dexamethasone was administered intravenously according to body weight in doses of 0.1 to 0.6 mg/kg in 11 studies 7,14,26,29,31,35,37,39,42,43,47 or as standard doses of 8 to 10 mg in 7 studies. 27,32,38,41,[44][45][46] The intrathecal dexamethasone dose used in the 3 studies was 8 mg. 28,36,40 The doses of intravenous hydrocortisone used were 1 to 2 mg/kg. 15,30,33,34 In most studies, the steroids or the controls were administered intravenously before or during induction of anesthesia.…”

“…Fifteen studies totaling 1750 patients were pooled to evaluate the effect of intravenous dexamethasone versus placebo (normal saline) on shivering risk. 7,14,26,27,31,32,35,38,39,[41][42][43][44][45][46] Intravenous dexamethasone was effective against placebo in decreasing the risk of shivering (RR, 0.49 [95% CI, 0.39-0.63]; P < .00001; I 2 = 72%; Supplemental Digital Content 4, Supplemental Figure 2, http://links.lww.com/AA/E421). In subgroup analysis, administration of intravenous dexamethasone was effective versus placebo in patients undergoing noncardiac surgery under either general (RR, 0.42 [95% CI, 0.34-0.53]; P < .00001; I 2 = 0%) and spinal anesthesia (RR, 0.64 [95% CI, 0.50-0.83]; P = .0008; I 2 = 66%).…”