Post Anesthesia Shivering refractory to demerol

[VentdependenT]

Came out of OR at 95, warmed up to 97, and still shivering a bit in the jaw and fingers.

No signs of anything else going on.

Gave demerol 12.5 X2. Symptoms abate somewhat but don't completely disappear.

Have any of you tried 150ucg of Clonidine IV for this?

Whabout this 8mg of zofran mojo?

---

Members don't see this ad.

 

[bullard]

I saw this on my PACU rotation last month and would love to hear potential solutions too.

 

[Fastrach]

He's still at 97 degrees... how bout a bair hugger and a heat lamp? 😀

 

[sensoricaine]

see http://www.anesthesia-analgesia.org/content/vol94/issue2/images/medium/43FF4.gif

good review article comparing efficacy
http://www.anesthesia-analgesia.org/cgi/content/full/94/2/453

Pharmacological Treatment of Postoperative Shivering: A Quantitative Systematic Review of Randomized Controlled Trials

 

[urgewrx]

Vecuronium works great for shivering.

 

[VentdependenT]

so does a 40meq bolus of KCL buddy

 

[Planktonmd]

Vecuronium works great for shivering.

 

[ProwlerturnGas]

I have used Stadol for post op shivering which worked very well.

 

[Lonestar]

Vec and Kcl are great ideas. how about some holy water to ward off "spirits"?

 

[fakin' the funk]

Came out of OR at 95, warmed up to 97, and still shivering a bit in the jaw and fingers.

No signs of anything else going on.

Gave demerol 12.5 X2. Symptoms abate somewhat but don't completely disappear.

Have any of you tried 150ucg of Clonidine IV for this?

Whabout this 8mg of zofran mojo?

How'd the pt get to 95 in the first place

 

[VentdependenT]

How'd the pt get to 95 in the first place

Dunno.

 

[UTSouthwestern]

Definitely warm the patient up a little more and put a warm blanket around the head.

If you use clonidine, start lower than 150 ucg. Start at 50 ucg and repeat Q5-10 min. X 3

It works well as does Stadol, but the primary treatment for this patient should be continued warming.


Vec should be reserved for only the finest of the Chicago penitentiary system or any doctor with an internet handle beginning with V and ending with t.

 

[Antibiotix2006]

Tramadol at the dose of 1 mg/kg works well for post anesthetic shivering. It usually stops shivering in a minute or two and lasts long enough for you to rewarm the patient.

 

[dhb]

If the patient is cold i think the first step is to warm them up. Sometimes when the patient is stressed out before surgery they tend to shiver post op even if they're warm then clonidine or midaz will work fine to get them chilling

 

[Planktonmd]

Tramadol at the dose of 1 mg/kg works well for post anesthetic shivering. It usually stops shivering in a minute or two and lasts long enough for you to rewarm the patient.

I was not aware that Tramadol injectable is now available in the U.S.
Is it?
Or are you referring to PO Tramadol?

 

[seinfeld]

i use clonidine frequently after meperidine has failed. I would also suggest starting low at 50mcg.

 

[urgewrx]

I didn't know we had clonidine IV in the US. So... I looked it up. We don't have clonidine IV in the US.

You are either foreign or making this up.

 

[Arch Guillotti]

I didn't know we had clonidine IV in the US. So... I looked it up. We don't have clonidine IV in the US.

You are either foreign or making this up.

Dude we add clonidine to our local anesthetic mixtures for regional anesthesia all the time.

 

[dhb]

I was not aware that Tramadol injectable is now available in the U.S.
Is it?
Or are you referring to PO Tramadol?

Damn, is an iv med the fcuking holy grail in the US or what 😱 you don't have iv acetaminofen which btw is class I OMS pain drug and you don't have iv tramadol 😱 (which is great for those demented patients post ortho surg)
weird

 

[urgewrx]

Dude we add clonidine to our local anesthetic mixtures for regional anesthesia all the time.

Yes, there is liquid clonidine for epidurals.... but have you ever injected that IV?

 

[Pilot Doc]

Vec should be reserved for only the finest of the Chicago penitentiary system or any doctor with an internet handle beginning with V and ending with t.

From a theoretical standpoint, does anyone know/suspect if a defasiculating type dose of vec would help shivering. (Not that the r/b ratio would be favorable, just curious.)

 

[coprolalia]

Yes, there is liquid clonidine for epidurals.... but have you ever injected that IV?

This is very, VERY off-label. I've seen it used before during the case to lessen the required opioid and overall anesthetic. Did I like it? Not so much. The patient took a LONG time to wake-up enough to get the tube pulled.

But, seems other alpha-2 agonsists may work, like dexmeditomidine. But, are you willing to use such an expensive (or unnapproved) drug in this instance when you've got cheaper and more readily available level? Again, active warming also works nice.

-copro

 

[2ndyear]

I was under the impression that the liquid clonidine was wicked expensive. I know Dex costs us about $56 for a 2 cc vial. I'll have to look up the clonidine.

 

[UTSouthwestern]

100 mcg/cc clonidine (10 cc vial) is $66.24
500 mcg/cc clonidine (10 cc vial) is $331.13
👎

 

[InductionAgent]

Damn, is an iv med the fcuking holy grail in the US or what 😱 you don't have iv acetaminofen which btw is class I OMS pain drug and you don't have iv tramadol 😱 (which is great for those demented patients post ortho surg)
weird

Patients are NPO when they first come into the recovery room, i.e. when they're most likely shivering. The risk of choking on a pill would only be increased in a shivering patient. And I haven't heard of PR tramadol.

 

[InductionAgent]

see http://www.anesthesia-analgesia.org/content/vol94/issue2/images/medium/43FF4.gif

good review article comparing efficacy
http://www.anesthesia-analgesia.org/cgi/content/full/94/2/453

Pharmacological Treatment of Postoperative Shivering: A Quantitative Systematic Review of Randomized Controlled Trials

Thanks for the link.

The first article mentioned doxapram 100mg as being highly effective, with a NNT of 1.7

Combined with its potential for optimizing respiration, doxapram seems an ideal choice (although I don't know its cost)

 

[urgewrx]

This is very, VERY off-label. I've seen it used before during the case to lessen the required opioid and overall anesthetic. Did I like it? Not so much. The patient took a LONG time to wake-up enough to get the tube pulled.

But, seems other alpha-2 agonsists may work, like dexmeditomidine. But, are you willing to use such an expensive (or unnapproved) drug in this instance when you've got cheaper and more readily available level? Again, active warming also works nice.

-copro

That's my point. People read papers on esoteric stuff and then talk like they do it all the time.

 

[dhb]

This is very, VERY off-label.

Not in Europe, i know places where it is given almost systematically as for the price, that seems to be out of whack 😱 here the price is 3.7 euros for 5 150 mcg vials
check it for yourself: http://www.cbip.be/ggr/index.cfm?ggrWelk=/nindex/ggr/stof/IN_C.cfm

UT if those prices are real i'm open to start shipping these over by the ton Escobar style 😎

Inducation agent, i was actually saying the contrary: it seems like you have less iv meds in the us compared to europe namely iv acetaminofen and apparently tramadol and clonidine (off label)

 

[Planktonmd]

Damn, is an iv med the fcuking holy grail in the US or what 😱 you don't have iv acetaminofen which btw is class I OMS pain drug and you don't have iv tramadol 😱 (which is great for those demented patients post ortho surg)
weird

Well,
We have a wonderful organization called the FDA that makes sure we stay at least 10 years behind the rest of the world.
and they are very successful at what they do.

 

[Antibiotix2006]

I was not aware that Tramadol injectable is now available in the U.S.
Is it?
Or are you referring to PO Tramadol?

Not PO, i'm talking about i.v tramadol. Sorry, I wasn't aware that it wasn't available in the US.

I've been using it for the last few years for post op shivering and it works pretty well. I had even done a small comparison trial of tramadol against meperidine in post op shivering.

These drugs mostly seem to modify the shivering threshold. Which means that you can have a patient who is hypothermic, but comfortable, after giving them tramadol. This gives you enough time to get them warmed up with a warmer or a bair hugger.

I remember one study I had read about which suggested giving Tramadol prior to extubation, which would result in a non-shivering patient.

On average, i've seen i.v tramadol stop shivering in less than 1 minute with very good success rates. (Only few instances where it hasn't worked!)

However, its best to give it over a minute or two, rather than an i.v push , else a few of the patients start getting nauseous.😱

 

[seinfeld]

Sure its off label, our clonidine syringes even state on them not for IV use, but then again the bupivcaine bottles that we use for CSE's or isobaric bupivicaine spinals say " not for spinal " ( which drug company will do the study for the FDA?). The literature has articles using IV clonidine (i looked at them back when i was a CA-1 but don't have any links currently). We, as standard ,use 300-400mcg IV clonidine for our liver transplants.

I agree that sedation and wake up are issues, that's why i generally only give it for inpatients in the PACU. Although bradycardia and hypotension are also issues i have not yet seen significant issues with proper patient selection, ie its not for the bradycardiac patient who is known to be hypovolemic. The times i really like it are for ETOH patients who are in pain and trying to get out of bed in the PACU.

If given preop, i would watch for problems with significant hypotension post induction especially if given along with opiods and 2-3 mg/kg of propofol, been there.. done that.. never do it again.

I would agree with copro that active warming is key, but i get more anxious and cant wait for the warming to help when a CAD patient is hypertensive and shivering in the PACU and meperidine is not working.

 

[coprolalia]

I agree that sedation and wake up are issues, that's why i generally only give it for inpatients in the PACU. Although bradycardia and hypotension are also issues i have not yet seen significant issues with proper patient selection, ie its not for the bradycardiac patient who is known to be hypovolemic.

First off, shivering is not necessarily bad in someone who has a good cardiac reserve. It is the body's active warming mechanism. I find that teenage kids are the ones most likely to shiver post-op, and rarely do they have a cardiac issue that would indicate shivering would "hurt" them. Likewise, shivering is usually self-limited and doesn't last for very long.

More importantly, is it (clonidine) safe to give IV in a cardiac patient? Personally, I would be very careful as a consultant using a drug off-label in a cohort of patients who may have a serious adverse outcome as a result.

-copro

 

[Arch Guillotti]

Yes, there is liquid clonidine for epidurals.... but have you ever injected that IV?

Our pediatric anesthesiologists give IV clonidine pretty routinely for the kids that have really bad delirium in the peds PACU. Sometimes if the kiddo has a history of waking up badly they will give it preemptively.

 

[Planktonmd]

Our pediatric anesthesiologists give IV clonidine pretty routinely for the kids that have really bad delirium in the peds PACU. Sometimes if the kiddo has a history of waking up badly they will give it preemptively.

Yeah,
If you make kids hypotensive enough they eventually stop screaming.

 

[Arch Guillotti]

Yeah,
If you make kids hypotensive enough they eventually stop screaming.

Dude I gave IV clonidine the other day for a case and it worked great. The kid was a strapping rock solid 200 lb 15 year old for ankle ORIF. I gave 2 mcg/kg IV. 50 mcgs x 2 doses, then a 100 mcg dose. There was no hypotension whatsoever. He seemed to take a bit longer to wake up but we didn't fool around with waiting for him. Since he was an was an easy airway and was breathing great on his own I yanked the ET tube. He was very comfortable in the PACU. If this kid had woken up like some of my young male teenagers (ie like a bat out of hell) he might have taken a few of us out. By giving the clonidine I am convinced that we avoided a nasty wake up. I would encourage everyone to give it a try in the appropriate circumstance.

 

[Gern Blansten]

One aspect of this that I have not seen mentioned in this thread is the risk in the patient with cardiovascular disease. Shivering will frequently lead to increased heart rate (bad with ischemic heart disease) and can potentially lead to ischemic changes seen on the EKG monitor. It is important to remember that a quick acting beta blocker (esmolol) is the best first choice for this patient to control the heart rate and thus help minimize ischemia by affecting the demand side of the supply and demand ratio. The patient can be warmed many different ways, but all of them take time. Beta blockers are the best choice in the above scenario with ongoing ischemia. I believe this is a written exam scenario that is frequently missed. Any comments? Agree/disagree?