Efficacy and safety of prophylactic use of ketamine for prevention of postanesthetic shivering: a systematic review and meta analysis

Efficacy of intravenous nalbuphine for managing post-anaesthesia shivering: A systematic review and meta-analysis of randomised controlled trials with trial sequential analysis

Background and Aims

Post-anaesthesia shivering is distressing and is observed after spinal and general anaesthesia. Nalbuphine, a partial mu-opioid receptor antagonist with kappa-opioid receptor agonist properties, has been successfully used to manage post-anaesthesia shivering.

Methods

After registering the review with the International Prospective Register of Systematic Reviews (PROSPERO), we searched PubMed/Medline, Scopus, Ovid, Cochrane Library and clinicaltrials.gov with keywords for randomised controlled trials. The risk of bias-2 (RoB-2) scale was used to assess the quality of evidence. We also used Grading of Recommendations, Assessment, Development and Evaluations (GRADE) guidelines to evaluate the strength of evidence and trial sequential analysis to validate the conclusions.

Results

Of the 240 articles, 10 were considered eligible for review (700 patients, 350- nalbuphine, 350- control or placebo). When compared to placebo, the success rate of nalbuphine controlling shivering was significantly better (risk ratio [RR]: 2.37, 95% confidence interval [CI]:1.91, 2.94; P = 0.04, I² = 94%), but comparable to the control group drugs (opioids, dexmedetomidine, ondansetron, pethidine). Compared to placebo, shivering recurrence was significantly less with nalbuphine than with placebo (RR: 0.47, 95% CI: 0.26, 0.83; P = 0.01, I² = 61%), but comparable with the control group. The incidence of postoperative nausea/vomiting (PONV) was significantly less with nalbuphine when compared to the control group (RR: 0.67, 95% CI: 0.47, 0.95; P = 0.02, I² = 37%), but PONV in the nalbuphine group was comparable to placebo (RR: 1.20, 95% CI: 0.68, 2.12; P = 0.54, I² = 0%). Other outcomes, like the grade of shivering and hypotension, were comparable between the nalbuphine and control groups.

Conclusion

Nalbuphine successfully controls post-anaesthesia shivering and reduces the recurrence of shivering.

Short-term cognitive effects of repeated-dose esketamine in adolescents with major depressive disorder and suicidal ideation: a randomized controlled trial

BACKGROUND

Ketamine and its enantiomer have rapid and robust effects on depressive symptom and suicidal ideation. Little is known about their cognitive effects in adolescents. We aimed to evaluate the short-term effect of esketamine on cognition in adolescents with major depressive disorder (MDD) and suicidal ideation.

METHOD

In this randomized-controlled trial, 51 participants aged 13-18 with MDD and suicidal ideation received three intravenous infusions of either esketamine (0.25 mg/kg) or midazolam (0.02 mg/kg). Four dimensions of the MATRICS Consensus Cognitive Battery (MCCB), including processing speed, working memory, verbal learning and visual learning, were assessed at Days 0, 6 and 12.

RESULTS

In the linear mixed model, a significant time main effect (F = 12.803, P < 0.001), drug main effect (F = 6.607, P = 0.013), and interaction effect (F = 3.315, P = 0.041) was found in processing speed. Other dimensions including working memory and verbal learning showed significant time main effect (all P < 0.05), but no significant drug or interaction effect (all P > 0.05). Esketamine group showed improvement in processing speed from baseline to Days 6 and 12, and working memory from baseline to Day 12 (all P < 0.05). The generalized estimation equation showed no significant association between baseline cognition and antidepressant or antisuicidal effect (both P > 0.05).

CONCLUSIONS

The present study suggested that three-dose subanesthetic esketamine infusions did not harm cognition among adolescents with MDD and suicidal ideation. Instead, esketamine may be associated with improvement in processing speed.

TRIAL REGISTRATION

This trial was registered in the Chinese Clinical Trials Registry ( http://www.chictr.org.cn , ChiCTR2000041232).

The effects of intravenous tramadol vs. intravenous ketamine in the prevention of shivering during spinal anesthesia: A meta-analysis of randomized controlled trials

Background

Shivering is a common complication after subarachnoid administration of local anesthetics. Intravenous ketamine and tramadol are widely available anti-shivering drugs, especially in developing settings. This meta-analysis aimed to compare the effects of intravenous ketamine vs. tramadol for post-spinal anesthesia shivering.

Materials and methods

PubMed/MEDLINE, Web of Science, Cochrane Library, Embase, and Google Scholar databases were used to search for relevant articles for this study. Mean difference (MD) with 95% confidence interval (CI) was used to analyze continuous outcomes, and risk ratio (RR) with 95% CI to analyze categorical results. The heterogeneity of the included studies was assessed using the I2 test. We utilized Review Manager 5.4.1 to perform statistical analysis.

Results

Thirteen studies involving 1,532 patients were included in this meta-analysis. Ketamine had comparable effects in preventing post-spinal anesthetics shivering [RR = 1.06; 95% CI (0.94, 1.20), P = 0.33, I ² = 77], and onset of shivering [MD = -0.10; 95%CI (- 2.68, 2.48), P = 0.94, I ² = 0%], lower incidences of nausea and vomiting [RR = 0.51; 95%CI (0.26, 0.99), P = 0.05, I ² = 67%], and lower incidences of bradycardia [RR = 0.16; 95%CI (0.05, 0.47), P = 0.001, I ² = 33%], higher incidence of hallucinations [RR = 12; 95%CI (1.58, 91.40), P = 0.02, I ² = 0%], and comparable effects regarding the incidences of hypotension [RR = 0.60; 95%CI (0.30, 1.21), P = 0.15, I ² = 54%] as compared to tramadol.

Conclusions

Intravenous ketamine and tramadol are comparable in the prevention of post-spinal anesthetic shivering. Ketamine had a better outcome with less occurrences of nausea, vomiting, and bradycardia. However, ketamine was associated with higher incidences of hallucinations than tramadol.

Evidence-Based Guideline on Prevention and Management of Shivering After Spinal Anesthesia in Resource-Limited Settings: Review Article

Background

Perioperative shivering is a common problem faced in anesthesia practice. Unless it is properly managed and prevented, it causes discomfort and devastating problems, especially in patients with cardiorespiratory problems. Surgery, anesthesia, exposure of skin in a cool operating theater, and administration of unwarmed fluids are some of the major causes for the development of shivering among surgical patients. Currently, a variety of non-pharmacological and pharmacological techniques are available to prevent and manage this problem. The available options to prevent and treat shivering include but are not limited to pre-warming the patient for 15 minutes before anesthesia administration, administration of low dose ketamine, dexamethasone, pethidine, clonidine, dexmedetomidine, tramadol, and magnesium sulfate.

Objective

To develop evidence-based recommendations for the prevention and management of shivering after spinal anesthesia in a resource-limited settings.

Methods

The kinds of literature are searched from Google Scholar, PubMed, Cochrane library, and HINARI databases to get access to current and update evidence on the prevention and management of shivering after spinal anesthesia. The keywords for the literature search were (shivering or prevention) AND (shivering or management) AND (anesthesia or shivering).

Conclusion

Pre-warming the patient with cotton, blanket, gown warming, and administering warm IV fluid 15 minutes before spinal anesthesia are possible non-pharmacologic options for the prevention of shivering. Furthermore, pharmacological medications like low dose ketamine, dexamethasone, magnesium sulfate, ad tramadol can be used as alternative options for the prevention and management strategies for shivering of different degrees in resource-limited areas.

Randomized clinical trial comparing outcomes after fentanyl or ketamine-dexmedetomidine analgesia in thoracolumbar spinal surgery in dogs

Background

Opioids are widely used for perioperative pain control in dogs undergoing spinal surgery, but alternatives may be required because data suggest that opioids exacerbate inflammation in the injured spinal cord and veterinary access to opioids may become more restricted in the future.

Objectives

To compare recovery of ambulation and other functions between spinal cord‐injured dogs receiving peri‐operative fentanyl and those receiving a ketamine‐dexmedetomidine combination.

Animals

A total of 102 client‐owned dogs undergoing decompressive surgery for thoracolumbar intervertebral disc herniation.

Methods

Randomized clinical trial. Dogs were randomized 1:1 to fentanyl or a ketamine‐dexmedetomidine combination for intra and postoperative analgesia. Primary outcome was time to recovery of ambulation; secondary outcomes were the postoperative Colorado Acute Pain Scale, the short‐form Glasgow Composite Measure Pain Scale, time to recovery of voluntary urination and time to unassisted eating.

Results

No difference was found in time to recovery of ambulation between groups (adjusted sub‐hazard ratio, 0.83; 95% confidence interval [CI], 0.55‐1.24; P = .36) or in pain scores (Colorado: χ² = 14.74; P = .32; Glasgow: χ² = 6.61; P = .76). Differences in time to recovery of eating and urination were small but favored ketamine‐dexmedetomidine (adjusted odds ratios, 3.31; 95% CI, 1.53‐7.16; P = .002 and 2.43; 95% CI, 1.00‐5.96; P = .05, respectively).

Conclusions and Clinical Importance

There was no evidence that, at the doses used, fentanyl impaired ambulatory outcome after surgery for thoracolumbar intervertebral disc herniation in dogs. Pain control appeared similar between groups. Secondary outcomes suggested minor benefits associated with ketamine‐dexmedetomidine. The ketamine‐dexmedetomidine combination appears to be a reasonable alternative to peri‐operative opioids.

Ondansetron for Shivering after Spinal Anesthesia in Cesarean Delivery: A Systematic Review and Meta-Analysis

PURPOSE

Evaluate the efficacy of ondansetron in preventing shivering after spinal anesthesia in cesarean delivery.

DESIGN

Systematic review and meta-analysis METHODS: Following the PRISMA statement, PubMed, CINAHL, Cochrane, EMBASE, Google scholar and other grey literature databases were searched for eligible studies.

FINDINGS

The overall incidence of shivering after spinal anesthesia in cesarean delivery is 32%, with 24% in patients who received ondansetron compared to 40% in the placebo group. A total of 19 trials consisting of 1399 patients were evaluated. Compared to placebo, ondansetron is effective in reducing the incidence of shivering (RR, 0.47; 95% CI, 0.29 to 0.78; P = 0.003). The quality of evidence is low due to substantial heterogeneity, imprecision and suspected publication bias. Patients who received ondansetron are less likely to require rescue treatment for shivering (RR, 0.34; 95% CI, 0.15 to 0.76; P = 0.009). Also, ondansetron is associated with a lower incidence of hypotension necessitating vasopressor treatment, and nausea and vomiting with no effects on the incidence of bradycardia.

CONCLUSION

Ondansetron is effective in mitigating shivering after spinal anesthesia in cesarean delivery.

Comparison of Intravenous Ketamine with Intrathecal Meperidine in Prevention of Post-anesthetic Shivering after Spinal Anesthesia for Lower Limb Orthopedic Surgeries: A Double-blind Randomized Clinical Trial

Background

Post-anesthetic shivering is one of the most common complications after anesthesia. Ketamine has been considered to be an effective treatment for post-anesthetic shivering, but the evidence for its therapeutic benefit after spinal anesthesia is limited. The aim of this study was to compare the effects of intravenous ketamine with intrathecal meperidine in the prevention of post-anesthetic shivering after spinal anesthesia for lower limb orthopedic surgeries.

Methods

In a double-blind randomized parallel-group clinical trial, a total of 150 patients scheduled for lower limb orthopedic surgeries under spinal anesthesia were selected and randomly divided into three equally sized groups of intravenous ketamine (0.5 mg/kg), intrathecal meperidine (0.2mg/kg) or intravenous normal saline (as placebo). The intensity of shivering in patients were evaluated during surgery and after transfer into the post anesthesia care unit. Also, changes in patients' drowsiness, nausea, vomiting, pruritus, mean arterial pressure, heart rate, and arterial oxygen saturation (SPO2) during surgery and until the end of anesthesia were evaluated.

Results

In all times of evaluation (20, 60, 80, 100 and 120 minutes after onset of spinal anesthesia) patients in control group showed a greater intensity of shivering compared to other groups. However, patients who received intrathecal meperidine experienced significantly lower intensity of post anesthetic shivering (p<0.05). The results showed a significant mean arterial pressure and heart rates differences between the three groups, only on 20 and 60 minutes after initiation of spinal anesthesia. The incidence of nausea, vomiting, and pruritus was not significantly different in all three groups, although all patients who received ketamine experienced drowsiness after surgery (p<0.001).

Conclusion

The results of the present study showed that, although both intrathecal meperidine and intravenous ketamine could effectively prevent postoperative shivering after spinal anesthesia in lower limb orthopedic surgeries, intrathecal meperidine was associated with more efficacy benefits and a lower frequency of side effects such as post-anesthesia drowsiness.

Effects of esketamine combined with ultrasound-guided nerve block on cognitive function in children with lower extremity fractures

OBJECTIVE

To explore the effect and complications of esketamine combined with ultrasound-guided nerve block in children with lower extremity fractures.

METHODS

120 children with fractures of lower extremities were included into the observation group (OG) and control group (CG) according to the specific anesthesia method. The OG was given esketamine combined with ultrasound-guided nerve block, and the CG was given ultrasound-guided nerve block combined with general anesthesia. Serum norepinephrine (NE), epinephrine (E), renin (R), mean arterial pressure (MAP), heart rate (HR), oxyhemoglobin saturation (SpO₂) and respiration rate (RR) were measured before, at 10, 20, and 30 min after anesthesia. The incidence of clinical complications and the anesthetic effects were compared between the two groups. The mini-mental state examination (MMES) scale was performed to evaluate the cognitive function of children in the two groups before and after surgery.

RESULTS

At 10 min and 20 min after anesthesia, the CG showed higher MAP and HR than the OG (P<0.05); however, RR and SpO₂ showed no difference between the two groups (P>0.05). At 30 min after anesthesia, HR and MAP were not significantly different between the two groups (P>0.05); NE, E, and R showed no significant difference before surgery (P>0.05), which were higher in CG than those in the OG after surgery (P<0.05). The success rate of nerve block and anesthesia were 91.67% and 85.00%, respectively in the OG, which were higher than 88.33% and 83.33% in the CG (P>0.05). The OG had a complication rate of 8.33%, significantly lower than that of 20.00% in the CG (P<0.05).

CONCLUSION

Esketamine combined with ultrasound-guided nerve block anesthesia was superior to ultrasound-guided nerve block combined with general anesthesia in children with lower extremity fractures, with fewer compilations.

[Inhalational anesthetics]

Inhalational anesthetics have been used for induction and maintenance of general anesthesia for more than 150 years. All of the currently used inhalational anesthetics are chlorinated and fluorinated derivatives of ether. Dosing is carried out using the minimal alveolar concentration (MAC) concept. The pharmacokinetic properties of the various inhalational anesthetics are governed by the specific distribution coefficients. Mechanisms of action include specific modulations of various receptors of the central nervous system as well as an unspecific interaction with the cell membrane. Organ toxicity of modern inhalational anesthetics is considered to be minimal. The role of inhalational anesthetics in the context of postoperative nausea and vomiting (PONV) has been reassessed in recent years. The superiority of inhalational anesthetics over intravenous hypnotics with respect to intraoperative awareness is undisputed. The organ protective mechanism of preconditioning is an exclusive property of inhalational anesthetics among all the currently available hypnotics.

Ultrasound-guided bilateral subcostal transversus abdominis plane block in gastric cancer patients undergoing laparoscopic gastrectomy: a randomised-controlled double-blinded study

BACKGROUND

The effectiveness of subcostal transversus abdominis plane block (TAPB) in laparoscopic gastric cancer surgery is unknown. We aimed to investigate its opioid-sparing and pain-relief effects in laparoscopic gastrectomy for gastric cancer.

METHOD

One hundred and twelve patients undergoing elective laparoscopic gastrectomy were randomised to the TAPB or control group. The TAPB group received ultrasound-guided bilateral subcostal TAPB at the end of surgery, while the control group did not. We investigated fentanyl consumption administered via intravenous patient-controlled analgesia and as a rescue analgesic, the numeric rating scale (NRS) pain scores at rest and during coughing, and the opioid-related side effects at 6, 12, 24, and 48 h postoperatively. The primary outcome was cumulative fentanyl consumption at 24 h postoperatively.

RESULTS

The study included 53 patients in each group. The cumulative fentanyl consumption 24 h postoperatively was significantly lower in the TAPB group than in the control group (median difference -170 mcg, P = 0.03, 95% CI -360 to -15 mcg). Subcostal TAPB also significantly reduced the resting NRS score at 48 h postoperatively (median difference -1, 95% CI -1 to 0, P = 0.01) and coughing NRS score at all time points (all median difference -1, 95% CI -2 to 0, P < 0.01, P  = 0.02, 0.01, and 0.01, respectively). However, it did not reduce the occurrence of opioid-related side effects, except the use of antiemetics during the first 6 h postoperatively (TAPB, 1.9% vs. Control, 15.1%, P = 0.03).

CONCLUSION

Ultrasound-guided bilateral subcostal TAPB provides efficient postoperative analgesia with an opioid-sparing effect after laparoscopic gastrectomy.

The Impact of Optimal Dose of Ketamine on Shivering Following Elective Abdominal Hysterectomy: A Randomised Comparative Study

Background

Following surgery, patients frequently suffer from shivering, and this can lead to postoperative complications and discomfort.

Objectives

This study aimed to compare the effect of ketamine on patients’ shivering following an elective abdominal hysterectomy. Patients were given either Ketamine (0.25 mg or 0.5 mg/kg) or a placebo. The study and surgery took place in a subspecialty University Hospital for Gynecology and Obstetrics.

Methods

This study was an interventional, randomized, controlled clinical trial. Ninety-six women who underwent elective abdominal hysterectomy were randomly assigned to three groups. Ketamine was administered to all participants 20 min prior to the end of surgery. The first group received 0.25 mg/kg of intravenous ketamine. The second group received 0.5 mg/kg intravenous ketamine. The third group received a placebo of intravenous saline. Postoperative shivering, sedation grade, hallucination, nausea, vomiting, and nystagmus were measured for each patient up to 30 minutes.

Results

The study showed that patients suffered from less shivering in the two groups that received ketamine. The reduced shivering was seen 5, 10, and 20 min following surgery in the two groups that were given two doses of 0.25 and 0.5 mg/kg ketamine compared to the control group (P value < 0.05). There was a significant difference between patients receiving normal saline and those having 0.25 and 0.5 mg/kg of ketamine in the rate of sedation grade, nausea, vomiting, and nystagmus (P value < 0.05). The main differences in patients receiving ketamine were the sedation grade at zero time and postoperative hallucination experienced by those patients who received 0.5 mg/kg of ketamine.

Conclusions

Ketamine reduced shivering in all patients following elective abdominal hysterectomy. This was regardless of dose. Patients were less likely to suffer from hallucinations and sedation grade with a lower dose of ketamine (0.25 mg/kg compared to 0.50 mg/kg).

Incidence of postoperative shivering decreased with the use of acetaminophen: a propensity score matching analysis

OBJECTIVES

The incidence of postoperative shivering is known to be inversely associated with core body temperature. However, previous studies have pointed out that the threshold of shivering could be affected by peripheral temperature or anesthetic agents. These reports pointed specific drugs, though, anesthesia techniques have since advanced considerably. This study aimed to investigate factors associated with postoperative shivering in the context of the current body warming practice.

METHODS

The institutional clinical research ethics committee of Kyushu University approved the study protocol (IRB Clinical Research number 2019-233). This retrospective study involved 340 patients who had undergone radical surgery for gynecological cancer treatment under general anesthesia at our center from December 2012 to June 2019. Logistic regression analysis was performed to estimate the odds ratio (OR) for the incidence of postoperative shivering.

RESULTS

Postoperative shivering developed in 109 out of 340 patients. After multivariate-adjusted logistic regression, the incidences of postoperative shivering decreased significantly with increasing patient age (OR = 0.96; 95%CI: 0.93-0.98; p = 0.0004). Volatile anesthesia technique was less inclined to shiver after surgery than TIVA (OR = 0.55; 95%CI: 0.30-0.99; p = 0.04). Acetaminophen was much less used in the shivering group than in the non-shivering group (OR = 0.49; 95%CI: 0.25-0.94; p = 0.03).

CONCLUSIONS

This study indicated that the development of shivering in patients receiving the anesthetic technique currently used in our hospital was associated with use of acetaminophen or volatile agents, and patient age.