Shivering Treatments for Targeted Temperature Management: A Review

Akash Jain, Maria Gray, Stephanie Slisz, Joseph Haymore, Neeraj Badjatia, Erik Kulstad, Akash Jain, Maria Gray, Stephanie Slisz, Joseph Haymore, Neeraj Badjatia, Erik Kulstad

Abstract

Background: Shivering is common during targeted temperature management, and control of shivering can be challenging if clinicians are not familiar with the available options and recommended approaches.

Purpose: The purpose of this review was to summarize the most relevant literature regarding various treatments available for control of shivering and suggest a recommended approach based on latest data.

Methods: The electronic databases PubMed/MEDLINE and Google Scholar were used to identify studies for the literature review using the following keywords alone or in combination: "shivering treatment," "therapeutic hypothermia," "core temperature modulation devices," and "targeted temperature management."

Results: Nonpharmacologic methods were found to have a very low adverse effect profile and ease of use but some limitations in complete control of shivering. Pharmacologic methods can effectively control shivering, but some have adverse effects, such that risks and benefits to the patient have to be balanced.

Conclusion: An approach is provided which suggests that treatment for shivering control in targeted temperature management should be initiated before the onset of therapeutic hypothermia or prior to any attempt at lowering patient core temperature, with medications including acetaminophen, buspirone, and magnesium sulfate, ideally with the addition of skin counterwarming. After that, shivering intervention should be determined with the help of a shivering scale, and stepwise escalation can be implemented that balances shivering treatment with sedation, aiming to provide the most shivering reduction with the least sedating medications and reserving paralytics for the last line of treatment.

Conflict of interest statement

E.K., S.S., and M.G. work with a company, Attune Medical, commercializing temperature management technology. For the remaining authors, no conflicts of interest were declared.

References

    1. Badjatia N. Hyperthermia and fever control in brain injury. Crit Care Med. 2009;37(7 suppl):S250-7–S250-7.
    1. Polderman KH. Induced hypothermia and fever control for prevention and treatment of neurological injuries. Lancet. 2008;371(9628):1955–1969.
    1. Rockett H, Thompson HJ, Blissitt PA. Fever management practices of neuroscience nurses: what has changed? J Neurosci Nurs. 2015;47(2):66–75.
    1. Badjatia N. Therapeutic temperature modulation in neurocritical care. Curr Neurol Neurosci Rep. 2006;6(6):509–517.
    1. Presciutti M, Bader MK, Hepburn M. Shivering management during therapeutic temperature modulation: nurses’ perspective. Crit Care Nurse. 2012;32(1):33–42.
    1. Badjatia N, Strongilis E, Gordon E, et al. Metabolic impact of shivering during therapeutic temperature modulation: the Bedside Shivering Assessment Scale. Stroke. 2008;39(12):3242–3247.
    1. Choi HA, Ko SB, Presciutti M, et al. Prevention of shivering during therapeutic temperature modulation: the Columbia anti-shivering protocol. Neurocrit Care. 2011;14(3):389–394.
    1. Hegazy AF, Lapierre DM, Butler R, Althenayan E. Temperature control in critically ill patients with a novel esophageal cooling device: a case series. BMC Anesthesiol. 2015;15:152.
    1. van Zanten AR, Polderman KH. Blowing hot and cold? Skin counter warming to prevent shivering during therapeutic cooling. Crit Care Med. 2009;37(6):2106–2108.
    1. Badjatia N, Strongilis E, Prescutti M, et al. Metabolic benefits of surface counter warming during therapeutic temperature modulation. Crit Care Med. 2009;37(6):1893–1897.
    1. Kasner SE, Wein T, Piriyawat P, et al. Acetaminophen for altering body temperature in acute stroke: a randomized clinical trial. Stroke. 2002;33(1):130–134.
    1. Weant KA, Martin JE, Humphries RL, Cook AM. Pharmacologic options for reducing the shivering response to therapeutic hypothermia. Pharmacotherapy. 2010;30(8):830–841.
    1. Boet R, Chan MT, Poon WS, Wong GK, Wong HT, Gin T. Intravenous magnesium sulfate to improve outcome after aneurysmal subarachnoid hemorrhage: interim report from a pilot study. Acta Neurochir Suppl. 2005;95:263–264.
    1. Kurz A, Ikeda T, Sessler DI, et al. Meperidine decreases the shivering threshold twice as much as the vasoconstriction threshold. Anesthesiology. 1997;86(5):1046–1054.
    1. Ikeda T, Kurz A, Sessler DI, et al. The effect of opioids on thermoregulatory responses in humans and the special antishivering action of meperidine. Ann N Y Acad Sci. 1997;813:792–798.
    1. De Witte JL, Kim JS, Sessler DI, Bastanmehr H, Bjorksten AR. Tramadol reduces the sweating, vasoconstriction, and shivering thresholds. Anesth Analg. 1998;87(1):173–179.
    1. Takada K, Clark DJ, Davies MF, et al. Meperidine exerts agonist activity at the alpha(2B)-adrenoceptor subtype. Anesthesiology. 2002;96(6):1420–1426.
    1. Doufas AG, Lin CM, Suleman MI, et al. Dexmedetomidine and meperidine additively reduce the shivering threshold in humans. Stroke. 2003;34(5):1218–1223.
    1. Kimberger O, Ali SZ, Markstaller M, et al. Meperidine and skin surface warming additively reduce the shivering threshold: a volunteer study. Crit Care. 2007;11(1):R29.
    1. Talke P, Tayefeh F, Sessler DI, Jeffrey R, Noursalehi M, Richardson C. Dexmedetomidine does not alter the sweating threshold, but comparably and linearly decreases the vasoconstriction and shivering thresholds. Anesthesiology. 1997;87(4):835–841.
    1. Polderman KH. Mechanisms of action, physiological effects, and complications of hypothermia. Crit Care Med. 2009;37(7 suppl):S186–S202.
    1. Honasoge A, Parker B, Wesselhoff K, Lyons N, Kulstad E, et al. First use of a new device for administration of buspirone and acetaminophen to suppress shivering during therapeutic hypothermia. Ther Hypothermia Temp Manag. 2016;6(1):48–51.
    1. Polderman KH, Herold I. Therapeutic hypothermia and controlled normothermia in the intensive care unit: practical considerations, side effects, and cooling methods. Crit Care Med. 2009;37(3):1101–1120.
    1. Fraser GL, Devlin JW, Worby CP, et al. Benzodiazepine versus nonbenzodiazepine-based sedation for mechanically ventilated, critically ill adults: a systematic review and meta-analysis of randomized trials. Crit Care Med. 2013;41(9 suppl 1):S30–S38.
    1. Singh P, Harwood R, Cartwright DP, Crossley AW. A comparison of thiopentone and propofol with respect to the incidence of postoperative shivering. Anaesthesia. 1994;49(11):996–998.
    1. Matsukawa T, Kurz A, Sessler DI, Bjorksten AR, Merrifield B, Cheng C. Propofol linearly reduces the vasoconstriction and shivering thresholds. Anesthesiology. 1995;82(5):1169–1180.
    1. Eydi M, Golzari SE, Aghamohammadi D, Kolahdouzan K, Safari S, Ostadi Z. Postoperative management of shivering: a comparison of pethidine vs. ketamine. Anesth Pain Med. 2014;4(2):e15499.
    1. Reddy AV, Kumer KK. Dexmedetomidine infusion versus intravenous low-dose ketamine injection in preventing intraoperative shivering during spinal anesthesia: a comparative study. J Med Sc Clin Res. 2017;5(8):26121–26128.
    1. Dupuis JY, Nathan HJ, DeLima L, Wynands JE, Russell GN, Bourke M. Pancuronium or vecuronium for treatment of shivering after cardiac surgery. Anesth Analg. 1994;79(3):472–481.
    1. Rello J, Diaz E, Roque M, Vallés J. Risk factors for developing pneumonia within 48 hours of intubation. Am J Respir Crit Care Med. 1999;159(6):1742–1746.

Source: PubMed

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