Preventing shivering with adjuvant low dose intrathecal meperidine: A meta-analysis of randomized controlled trials with trial sequential analysis

Abstract

The aim of this systematic review and meta-analysis is to evaluate the pros and cons of adjuvant low dose intrathecal meperidine for spinal anaesthesia. We searched electronic databases for randomized controlled trials using trial sequential analysis (TSA) to evaluate the incidence of reduced rescue analgesics, shivering, pruritus, nausea and vomiting when applying adjuvant intrathecal meperidine. Twenty-eight trials with 2216 patients were included. Adjuvant intrathecal meperidine, 0.05–0.5 mg kg−1, significantly reduced incidence of shivering (relative risk, RR, 0.31, 95% confidence interval, CI, 0.24 to 0.40; TSA-adjusted RR, 0.32, 95% CI, 0.25 to 0.41). Intrathecal meperidine also effectively reduced need for intraoperative rescue analgesics (RR, 0.27, 95% CI, 0.12 to 0.64; TSA-adjusted RR, 0.27, 95% CI, 0.08 to 0.91) and the incidence of pruritus was unaffected (RR, 2.31, 95% CI, 0.94 to 5.70; TSA-adjusted RR, 1.42, 95% CI, 0.87 to 2.34). However, nausea and vomiting increased (RR, 1.84, 95% CI, 1.29 to 2.64; TSA-adjusted RR, 1.72, 95% CI, 1.33 to 2.23; RR, 2.23, 95% CI, 1.23 to 4.02; TSA-adjusted RR,1.96, 95% CI, 1.20 to 3.21). Under TSA, these results provided a sufficient level of evidence. In conclusion, adjuvant low dose intrathecal meperidine effectively attenuates spinal anaesthesia-associated shivering and reduces rescue analgesics with residual concerns for the nausea and vomiting.

The Effect of Intrathecal Meperidine on Maternal and Newborn Outcomes After Cesarean Section: A Systematic Review and Meta-Analysis Study

“…In the study of Shami et al (10), Farzi et al (11), and Rastegarian et al (9), there was no statistically significant difference in nausea and vomiting between the two pethidine and control groups. On the contrary, Lin et al (20) reported the increased risk of nausea and vomiting in their meta-analysis, which is consistent with the results in the present study.…”

“…In a meta-analysis by Lin et al (20) on the effect of the intrathecal pethidine (5/25 mg) on various surgeries, they revealed that a minimum dose of pethidine reduced significantly shivering and increased the demand for sedatives; however, the risk of nausea and vomiting is increased Shivering during the spinal anesthesia owns a multifactor mechanism. The sympathetic block, due to the spinal anesthesia, causes disturbance compensatory vasoconstriction and automatic adjustment below the level of blockage and slows down the thermoregulation, which leads ultimately to the vasodilatation and hypothermia.…”

“…Pethidine is one of the most commonly used drugs for treating and preventing both shivering and pain, which is more effective in controlling these two rather than the other sedatives (20,39). Although the mechanism of the effect of pethidine on shivering and pain control is not clear, it may be probably due to its direct effect on the temperature regulation center or its agonistic effects on the sedative receptors of µ and (40,41).…”

“…Pethidine is an intermediate lipid-soluble opioid with both a postoperative analgesic mechanism and a sensory block which is known as the only substance used in the cesarean section under spinal anesthesia. However, pethidine can cause a number of complications such as hypotension, vomiting and respiratory depression (20,21).…”

Postanaesthetic shivering – from pathophysiology to prevention

“…In the systematic quality assessment of published antishivering protocols of Choi et al a variety of individual and combination treatments were recommended, but skin warming and meperidine use were the most commonly cited strategies [3]. Regarding intrathecal via low dose intrathecal meperidine as an adjuvant for spinal anaesthesia could effectively prevent shivering and reduce need for rescue analgesics, yet still might increase the risk of nausea and vomiting [39]. Chiang et al studied the relationship between PS and free flap failure owing to postoperative compromise, and demonstrated that an optimal dose of meperidine could prevent PS, which is shown to be associated with a decrease in the incidence of the early post-surgical re-exploration rate of these free flaps related to circulatory compromise [40].…”