|Year : 2007 | Volume
| Issue : 1 | Page : 28-31
Tramadol for control of shivering (Comparison with pethidine)
Aditi A Dhimar1, Mamta G Patel1, VN Swadia2
1 M.D., Asst. Prof. Department of Anaesthesiology, Medical College and S.S.G. Hospital, Vadodara, India
2 MD., D.A., Prof. and Head, Department of Anaesthesiology, Medical College and S.S.G. Hospital, Vadodara, India
|Date of Acceptance||08-Dec-2006|
|Date of Web Publication||20-Mar-2010|
Aditi A Dhimar
26, Shaishav colony, B/H Yash complex, Gotri Road, Vadodara - 390021
Source of Support: None, Conflict of Interest: None
Shivering is common problem faced by an anaesthesiologist during intraoperative as well as in postoperative period. Shivering occurs during both general anaesthesia and regional anaesthesia, but it is more frequent and troublesome during regional anaesthesia. This randomized, prospective study conducted in 60 ASA grade I, II, or III patients, was designed to explore the efficacy and potency of Tramadol in comparison to Pethidine for control of shivering under regional anaesthesia. Patients received Tramadol or Pethidine in a dose of 1mg.kg -1 I.V after the appearance of shivering. Disappearance and recurrence of shivering, as well as haemodynamics were observed at scheduled intervals. Onset of disappearance of shivering was found at 1 minute in Tramadol group (T)( p < 0.05) and at 3 minutes in Pethidine group (P)( p < 0.05 ). The complete disappearance of shivering took 5 minutes in T group while 20 minutes in P group.Reccurence rate of shivering was 10% in T and 50% in P group patients respectively (p < 0.05). None of the patients had any complications except nausea and vomiting (6.6% and 20% in group T and P respectively, p> 0.05). Thus Tramadol and Pethidine were equally efficacious, but Tramadol was more potent with respect to control of shivering and its recurrence .It was concluded that I.V Tramadol is qualitatively superior to Pethidine for control of shivering.
Keywords: Shivering, Tramadol, Pethidine, Regional anaesthesia
|How to cite this article:|
Dhimar AA, Patel MG, Swadia V N. Tramadol for control of shivering (Comparison with pethidine). Indian J Anaesth 2007;51:28-31
|How to cite this URL:|
Dhimar AA, Patel MG, Swadia V N. Tramadol for control of shivering (Comparison with pethidine). Indian J Anaesth [serial online] 2007 [cited 2015 Jul 3];51:28-31. Available from: http://www.ijaweb.org/text.asp?2007/51/1/28/61111
| Introduction|| |
Regional anaesthesia is a safe and popular anaesthetic technique for various surgeries. Around 40-60% of the patients under regional anaesthesia develop shivering. ,
Shivering can be very unpleasant and physiologically stressful for the patients after enjoying the comforts of modern anaesthetics. Mild shivering increases oxygen consumption to a level that is produced by light exercise, whereas severe shivering increases metabolic rate and oxygen consumption up to 100-600%. It may induce arterial hypoxemia, lactic acidosis, increased IOP and ICT and interferes with ECG monitoring, pulse rate, B.P etc. ,, Shivering may be detrimental to the patients with low cardiorespiratory reserves.  It is uncomfortable to the parturients as well as to the operating room personnel, especially during regional anaesthesia. 
Various methods are available for the control of shivering during anaesthesia.
Non-pharmacological methods using equipments to maintain normothermia are effective but may be expensive and are not practical in all the settings. Pharmacological methods using various drugs like Pethidine, Clonidine, Doxapram, Ketanserine, Tramadol, Nefopam etc. have been tried which are simple, cost effective and easily available. Here we have compared Tramadol, a newer synthetic opioid with Pethidine, the gold standard drug for the treatment of shivering, in the quest for more safer and efficacious drug. We conducted this study to compare the efficacy, potency, haemodynamics effects and complications or side effects of Tramadol with that of Pethidine for the control of shivering.
| Materials and methods|| |
A prospective double blind randomized study was conducted at Medical college and S.S G Hospital Vadodara. After obtaining approval from the ethical committee a total of 60 patients from either gender, aged between 20-60 yrs, of ASA PS I, II or III undergoing various surgeries under regional anaesthesia were taken for the study. Sample size chosen for the study was based on assuming the power of 80%, ? value of 0.05 and statistically significant difference between the two groups. Patients with fever, thyroid disease, obesity, diabetes, drug allergy, compromised cardiorespiratory conditions and patients on long term phenothiazines and MAO inhibitors were excluded from the study.
After premedication in the form of inj. Atropine or Glycopyrrolate I.V. Baseline preoperative axillary temperature was noted in all the patients. Central neural blockade (Spinal, Epidural And Combined Spinal and Epidural) or peripheral neural blockade was given according to the surgical procedures. Patients who experienced shivering of grades as shown in the [Table 1] were enrolled for the study.
All the patients who experienced shivering were randomly divided into Group T and Group P. Group T received 1% Tramadol in a dose of 1 mgkg -1 and Group P received 1% Pethidine in a dose of 1 mgkg -1 . All the patients were assessed for shivering grades, its disappearance, haemodynamic status, and complications if any. Patients were observed at intervals of 1 min till 5 mins, and thereafter at 10,20, 30, 45,and 60mins.Pulse rate, B.P, SPO 2 , Respiratory rate, and temperature were noted immediately after regional anaesthesia, and also during shivering, and thereafter the drug administration at regular intervals. Recurrence of shivering was also noted and an additional dose of either Tramadol or Pethidine in a dose of 0.5 mgkg -1 .was given in respective groups. Statistical analysis was done by EPI infoversion 6.04 January 2001 software package using unpaired student ' t' test and chi square test.
| Results|| |
In our study, both the groups were comparable with regards to age, weight, gender, and ASA physical status. [Table 2].
There was no significant difference found in the duration of surgery, axillary temperature as well as shivering grades at the start of study between the two groups [Table 3].
The onset of disappearance of shivering was found at around 1minute and 3 minutes in Group T and Group P respectively. Regarding the disappearance of shivering in both the groups ,we found a statistically significant difference as shown in the [Table 4] and graph-1. Stoppage of shivering occurred earlier in Group T in comparison to Group P (P<0.001) as shown in [Table 4].
The recurrence of shivering was observed approximately after 50 minutes and the incidence of recurrence was 50% in Pethidine group while only in 10% in Tramadol group as shown in [Table 6].
After repeating the drug shivering had disappeared completely. Complications like nausea and vomiting occurred in 20% in Pethidine group while only 6.66% in Tramadol group. However the difference is statistically insignificant.(P> 0.05).
| Discussion|| |
Regional anaesthesia including central neural blockade and peripheral nerve blockade is a safe and popular technique for various surgeries. Around 40-60% of the patients under regional anaesthesia develop shivering, though it is found commonly after general anaesthesia.  The probable mechanism under regional anaesthesia could either be a result of decrease in core body temperature or misinformation from receptors.  The factors causing decrease in core body temperature include, sympathetic block causing peripheral vasodilation, increased cutaneous blood flow resulting in increased heat loss through skin, cold operating room, rapid infusion of cold i.v fluids, direct effect of cold anaesthetic solution upon the thermosensitive structures of spinal cord , . Shivering may represent an inappropriate programmed thermal response to rise in body temperature.  Even local anaesthetic introduced into the extradural space might modify environmental thermal clues, with resultant inappropriate thermal responses to false information.  Shivering increases oxygen requirement by 100-600%, causes arterial hypoxemia, lactic acidosis, increase in BMR, I.O.P, ICT, and may prove detrimental to patients with low cardiorespiratory reserve. The parturients experienced it to be uncomfortable after enjoying the benefits of modern anaesthesia.
Various nonpharmacological and pharmacological methods have been used to prevent body heat loss. Nonpharmacological methods like electrical heaters, forced air warmers, blankets, radiant heat, and warming the operating room suite. The use of warm local anaesthetic solutions or warming of i.v fluids are also effective to reduce shivering. , Pharmacological methods using Ketanserine Nefopam, Pethidine, Alfentanyl, Doxapram, Tramadol, Clonidine etc have been tried and compared by many studies. These drugs are used effectively when clinically indicated and they are easily available to all centers and prove to be practical in the many settings.
In our study we have compared recently introduced synthetic opioid Tramadol with Pethidine, which was gold standard for control of shivering. Tramadol a synthetic opioid agonist prevents shivering by inhibiting the reuptake of norepinephrine and serotonin, hence activating the descending inhibitory spinal pathways. It also modulates the activity of nucleus median raphe acting centrally on the m opioid receptors predominantly with minimal effects on k and d receptors where as Pethidine acts mainly through opioid receptors namely k? receptors. The mechanism of action of Tramadol is different from that of Pethidine. Tramadol has minimal effect on k? receptors. The antishivering effect of Tramadol is mediated via serotonergic or noradrenergic receptor or both. , Pethidine controlled shivering better than Fentanyl and Morphine. 14 Therefore we undertook a study to compare a newer agent with a time-tested drug.
In our study we observed that shivering disappeared by 1 minute in case of Tramadol and 5 minutes in case of Pethidine and in comparison to earlier study, shivering reduced significantly at 1 minute after Tramadol but the dose was 2 mgkg -1 .  Furthermore, the complete disappearance of shivering took 10 minutes in Tramadol group and 20 minutes in Pethidine group. However in our study the complete disappearance of shivering occurred by the end of 5 minutes in case of Tramadol and 20 minutes in Pethidine group. Earlier studies have showed better results with Tramadol group. ,
Regarding recurrence, shivering reappeared after 50 minutes in 10% patients of Tramadol group and 50 % in Pethidine Group. The difference was statistically significant ( Z=8.207, P<0.05). The findings were in consolence with other studies which noted 8% with Tramadol group  and 13-50% in Pethidine group , Thus various studies including ours there was higher rate of recurrence with Pethidine in comparison to Tramadol. The second dose of the drug controlled the shivering completely but the possibility of respiratory depression with Pethidine should be borne in mind. The probable reason for recurrence of shivering could be result of low plasma concentration of the active drug, when hypothermia is still persisting and individual variations in the core temperatures. Till date it is not clear whether higher shivering grades requires a higher doses of the drug. 
In our study both the drugs gave good and better haemodynamic stability throughout the course of the study in all the patients. No respiratory depression was observed in any of the cases. Only in 20 % of cases from Pethidine group had nausea and vomiting which was easily treated with H 2 receptor blocker and antiemetic drug. Earlier studies have found that use of 1 mgkg -1 of Tramadol was associated with higher incidence of nausea and vomiting, and also sedation, which was not observed in our study.  Some others have suggested that slow injection of Tramadol over 2 minutes, reduces and prevents nausea and vomiting.  In our study we injected 1% Tramadol and Pethidine I.V slowly in all the cases.
We can derive at a conclusion that Tramadol is effective in treating shivering under regional anaesthesia due to its rapid onset, effective control, less recurrence rate and minimum side effects in a dose of 1 mgkg -1 . when compared to Pethidine. Similarly Tramadol was effective and safe in comparison to Pethidine for control of shivering as noted earlier ,, even recommend for Tramadol on prophylactic basis also. [Table 5]
| References|| |
|1.||De Whitte, Sessler DI, et al. Perioperative shivering: Physiology and Pharmacology. Anaesthesiology 2002; 96(2): 467-84. |
|2.||Sessler DI, Jose Ponte, et al. Shivering during epidural anaesthesia. Anesthesiology 1990; 72: 816-21. |
|3.||Bhatnagar S, Saxena A et al. Tramadol for postoperative shivering: a double blind comparison with Pethidine. Anesth Intensive care 2001; 29: 149-54. |
|4.||Katyal Sunil, Tewari Anurag et al. Shivering: Anesthetic Considerations. J Anaesth Clin Pharmacol 2002; 18(4): 363-76. |
|5.||Sessler Daniel I. Temperature Monitoring. Textbook of Anaesthesia; Ronald D Miller 5t h edition, Churchill Livingstone Inc. 1994: 1367-89. |
|6.||Mathews S, Al Mulla A et al. Postanaesthetic shivering-a new look at Tramadol. Anaesthesia 2002; 57: 387-403. |
|7.||Anne Miu Han Chan, Kwok Fu et al. Control of shivering under regional anaesthesia in obstetric patients with Tramadol.Can J Anesth 1999; 46(3): 253- 58. |
|8.||Eberhart L H, Roewer N et al. Pharmacological treatment of postoperative shivering: a quantitative systemic review of randomized controlled trials. Anesth Analg 2002; 94(2): 453-60. |
|9.||Chaturvedi S, Domkondwar G. Control of shivering under regional anaesthesia using Tramadol. Asian Archives of Anaesthesiology and Resuscitation 2002; 57: 491-96. |
|10.||Pamela J, Webb et al. Shivering during epidural analgesia in women in labour. Anaesthesiology 1981; 55: 706-07. |
|11.||Wrench J Cavill et al. Comparison between Alfentanil, Pethidine, and placebo in the treatment of postoperative shivering. Br J Anaesth. 1997; 79: 541-42. |
|12.||Takehiko I, Sessler Daniel I et al. Meperidine and Alfentanyl do not reduce the gain or maximum intensity of shivering. Anaesthesiology 1998; 88(4): 858-65. |
|13.||Write J De Deloof, T et al. Tramadol in the treatment of post anesthetic shivering. Acta Anaesthesiol Scand 1997; 41: 506-10. |
|14.||Singh P, Dimitriou V et al. Double blind comparison between Doxapram and Pethidine in the treatment of postanaesthetic shivering . Br J Anaesth 1993; 71: 685-88. |
|15.||Pausawasdi S, Jirasirithum S et al. The use of Tramadol hydrochloride in treatment of post-anesthetic shivering Med Assoc Thai 1990; 73: 16-20. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]