|Year : 2017 | Volume
| Issue : 2 | Page : 65-69
Comparison between intrathecal nalbuphine and intrathecal pethidine in preventing postspinal shivering after knee arthroscopy
Eslam N Nada MD , Gehan F Ezz
Department of Anaesthesia and Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
|Date of Submission||16-Nov-2016|
|Date of Acceptance||01-Mar-2017|
|Date of Web Publication||12-May-2017|
Eslam N Nada
Department of Anaesthesia and Intensive Care, Faculty of Medicine, Zagazig University, Flat 702, Moahada Street, El Hedaya Tower 1, El Sharkia, Zagazig - 44519
Source of Support: None, Conflict of Interest: None
Postspinal shivering is an annoying problem that can lead to many complications. The aim of the present study was to compare the effect of intrathecal nalbuphine with intrathecal pethidine in preventing postspinal shivering in patients undergoing knee arthroscopy.
Patients and methods
For this randomized study, we included 100 patients (American Society of Anesthesiologists physical status I or II) who were candidates for knee arthroscopy under spinal anesthesia. Participants were divided into two groups: group P (pethidine group, n=50) received 2.5 ml of 0.5% bupivacaine with 25-mg pethidine (total 3 ml) intrathecally, and group N (nalbuphine group, n=50) received 2.5 ml of 0.5% bupivacaine with 0.4-mg nalbuphine (total 3 ml) intrathecally. After establishment of standard monitoring, insertion of venous catheter, and applying the crystalloid infusion warmed to 37°C, intravenous atropine 0.6 mg was administered to all patients. Next, intrathecal block was performed at the L4–L5 level. All patients were operated in the same operating room at a temperature of 23°C. Mean arterial blood pressure, heart rate, arterial oxygen saturation, core (tympanic) temperature, incidence and severity of shivering, and incidence of complications were recorded at baseline, immediately after administration, and then every 5 min until end of surgery.
Hemodynamic parameters, oxygen saturation, and core temperature were comparable between the two groups. On the other hand, although incidence and intensity of shivering were lower in group P, there was no significant statistical difference between both groups − nine (18%) patients in group P and 17 (34%) patients in group N (P=0.109). In addition, the incidence of complications (hypotension, nausea, and pruritus) was lower in group P but without any significant statistical difference between the two groups.
Intrathecal nalbuphine is comparable with intrathecal pethidine in preventing postspinal shivering in patients undergoing knee arthroscopy.
Keywords: nalbuphine, pethidine, shivering, spinal anesthesia, thermoregulation
|How to cite this article:|
Nada EN, Ezz GF. Comparison between intrathecal nalbuphine and intrathecal pethidine in preventing postspinal shivering after knee arthroscopy. Res Opin Anesth Intensive Care 2017;4:65-9
|How to cite this URL:|
Nada EN, Ezz GF. Comparison between intrathecal nalbuphine and intrathecal pethidine in preventing postspinal shivering after knee arthroscopy. Res Opin Anesth Intensive Care [serial online] 2017 [cited 2018 Jun 24];4:65-9. Available from: http://www.roaic.eg.net/text.asp?2017/4/2/65/206148
| Introduction|| |
The vasodilation occurring below the level of blockage after neuraxial anesthesia causes loss of thermoregulation with body heat redistribution from the central to the peripheral compartment, leading to a decrease in central body temperature. The incidence of shivering ranges from 40 to 60% in patients receiving spinal anesthesia .
Shivering is a protective reflex that increases the production of body heat through muscle contraction. It is defined as an involuntary, repetitive activity of one or more skeletal muscles .
Postanesthetic shivering leads to feelings of discomfort in patients as well as increase in oxygen consumption, carbon dioxide production, catecholamine release, cardiac output, intraocular pressure, heart rate, and blood pressure. Moreover, shivering may inhibit accurate monitoring by causing artifacts in the monitor ,,,. Shivering also increases intracranial pressure, and may lead to increased wound pain, delayed wound healing, and delayed discharge from postanesthetic care ,. Management of shivering includes both pharmacological and nonpharmacological methods. The nonpharmacological methods include external heating such as use of forced air warming, warming blankets, and warmed fluids .
However, many drugs have been used for the treatment or prevention of postoperative shivering, such as clonidine, pethidine, tramadol, nefopam, ketamine , alfentanil , midazolam , magnesium sulfate , pentazocine , and ondansetron .
Pethidine, a μ-receptor and κ-receptor agonist, has a more prominent effect in the prevention and treatment of postoperative shivering than other opioids, may be because of stimulation of the κ-receptor apart from its nonopioid antishivering effects such as monoamine reuptake inhibition, N-methyl-d-aspartate receptor antagonism, and stimulation of α-2 receptors .
Nalbuphine is a lipophilic, semisynthetic, agonist–antagonist opioid related to both oxymorphone and naloxone. It has µ-antagonist and κ-agonist activities. It’s µ-antagonistic properties are responsible for fewer µ-mediated side effects such as respiratory depression, pruritus, nausea, and vomiting. Intrathecal nalbuphine is widely used for postoperative analgesia, and it can have a significant effect on postanesthetic shivering ,.
The aim of this study was to compare the effect of intrathecal nalbuphine with the effect of intrathecal pethidine in preventing postspinal shivering in patients undergoing knee arthroscopy.
| Patients and methods|| |
This randomized clinical study was performed in Zagazig University Hospitals, Zagazig, Egypt. After obtaining approval from the hospital ethics committee, written informed consents were obtained from 100 patients who were scheduled for knee arthroscopy under spinal anesthesia. Patients were aged between 18 and 45 years, of both sexes, with American Society of Anesthesiologists (ASA) physical status I or II.
Exclusion criteria were as follows: contraindications to regional anesthesia, allergy to any of the used drugs, BMI at least 30, drug addiction, tympanic temperature at least 37.6°C, and presence of diabetes and peripheral vascular disease.
Patients were divided randomly using closed envelops into two groups −group P (pethidine group, n=50) and group N (nalbuphine group, n=50).
For each patient, an 18-G peripheral venous catheter was inserted, and 500 ml of ringer’s lactate was infused before and during the blockade at a rate of 10 ml/kg/h.
Room temperature was maintained at 23°C, and all infusion and irrigation fluids were warmed to 37°C before administration.
After establishing standard monitoring, all patients received intravenous atropine 0.6 mg. Intrathecal block was performed in the sitting position at the L4–L5 level, midline approach, using 25-G Quincke needle (Ghatwary Medical Company, Alexandria, Egypt).
A volume of 2.5-ml hyperbaric bupivacaine 0.5% with 25 mg pethidine (total 3 ml) was injected intrathecally to group P patients, and a mixture of 0.4 mg nalbuphine made up to 0.5 ml by adding normal saline plus 2.5 ml hyperbaric bupivacaine 0.5% (total 3 ml) was injected intrathecally to group N patients.
Patients were positioned supine. An oxygen mask was placed with a flow rate of 5 l/min. Sensory levels were determined by pinprick after block, and every minute until it was fixed for five consecutive minutes. The motor blockade was evaluated using Bromage’s criteria.
Mean arterial blood pressure, heart rate, arterial oxygen saturation, tympanic temperature (measured by the BRAUN Thermoscan type 6022; Germany), and the incidence and intensity of shivering were measured and recorded preoperatively and then every 5 min until the end of surgery. The highest sensory level, the time to reach this level, and duration of surgery were also recorded.
Assessment of shivering intraoperatively and in the recovery room was carried out using Bedside Shivering Assessment Score as follows :
- None, no shivering noted on palpation of the masseter, neck, or chest wall.
- Mild, shivering localized to the neck and/or thorax only.
- Moderate, shivering involves gross movement of the upper extremities (in addition to the neck and thorax).
- Severe, shivering involves gross movements of the trunk and upper and lower extremities.
Shivering was treated with intermittent doses of pethidine 25 mg intravenously.
Hypotension (decrease in blood pressure by more than 20% of basal readings) was managed by ephedrine 0.1 mg/kg intravenously, with increments until control of blood pressure. However, bradycardia (heart rate<60 beats/min) was treated by intravenous atropine 0.01 mg/kg.
Any other complications were recorded.
The primary outcome was the difference in the incidence of shivering (≥2 Bedside Shivering Assessment Score) between both groups.
A sample size of 90 patients (45 patients in each group) was needed to achieve 80% power to detect 50% difference in the incidence of postspinal shivering between the two groups. We included 100 patients (50 patients in each group) to replace any dropouts.
The collected data were analyzed by Statistical Package for Social Science version 16 (SPSS Inc., 233 South Wacker Drive, 11th Floor, Chicago, IL 60606-6412). Data are expressed as mean±SD or as numbers and percentages of the total number of patients. Sex and ASA physical status were analyzed using the χ2-test. Highest sensory level, incidence of shivering, incidence of hypotension, and other complications were analyzed by Fisher’s exact test. Other parameters were analyzed using student’s t-test. A P-value less than 0.05 was considered statistically significant.
| Results|| |
The demographic data, ASA physical status, highest sensory block level, time to reach this level, and duration of surgery ([Table 1]) showed no significant statistical differences between both groups. Heart rate ([Table 2]), mean arterial blood pressure ([Table 3]), arterial oxygen saturation ([Table 4]), and core temperature ([Table 5]) were comparable between both groups.
|Table 1 Demographic data, duration of surgery, time to reach the highest level of sensory block, and sensory level (N=50)|
Click here to view
Regarding incidence of shivering ([Table 6]), although it was lower in group P (9/50) compared with group N (17/30), there was no significant difference between the two groups (P=0.109). Moreover, the intensity of shivering was comparable between both groups with insignificant difference.
There was no need for additional doses of atropine in all patients. In contrast, 12 patients in group P and 10 patients in group N developed hypotension and received ephedrine with insignificant difference between the two groups (P=0.809) ([Table 7]).
Ten patients in group P versus four patients in group N developed nausea without vomiting with no significant statistical difference between both groups (P=0.147).
Only two patients in group P developed pruritus (P=1) ([Table 7]).
| Discussion|| |
To our knowledge, thus far, no studies comparing intrathecal pethidine with intrathecal nalbuphine in preventing postspinal shivering have been carried out.
Hypothermia, defined as reduction in central blood temperature below 36°C, occurs during surgery because of many factors; the most important ones are direct inhibition of thermoregulation by anesthetics, decreased metabolism, exposure to a cold environment, and body cavity exposure .
Because of its complications, management of shivering is very important. Intravenous drug administration including nalbuphine is considered the ‘gold standard’ for the treatment of postoperative shivering ,,.
While using intrathecal nalbuphine for postoperative analgesia, its antishivering effect was significantly apparent ,. The study by Eskandr and Ebeid  showed that adding a small dose (400 µg) of nalbuphine to intrathecal bupivacaine versus placebo during anesthesia for knee arthroscopy reduced the incidence and severity of shivering without hemodynamic effects, which was concurrent with our results, considering the use of the same dose of intrathecal nalbuphine. In our study, we found that adding a small dose (400 µg) of nalbuphine to intrathecal bupivacaine during anesthesia for knee arthroscopy was comparable with the results after adding intrathecal pethidine 25 mg mixed with bupivacaine in reducing the incidence and severity of shivering with insignificant differences in hemodynamic changes, core temperature changes, and incidence of complications.
Pethidine can be considered the most effective opioid agonist of µ and κ receptors in the treatment and prevention of shivering. Intravenous pethidine is much more effective in treating shivering than equivalent doses of other opioid agonists such as fentanyl, alfentanil, sufentanil, or morphine .
There are many studies that have evaluated the effects of intrathecal pethidine on postspinal shivering. In our study, we chose to use the standard intrathecal pethidine dose of 25 mg (0.3–0.4 mg/kg) to obtain satisfactory antishivering effects.
Other studies performed by Chen et al. , Roy et al. , and Chun et al.  used a dose of 0.2 mg/kg intrathecal pethidine that was effective in decreasing the incidence of postspinal shivering.
The study by Anaraki and Mirzaei’s  showed that a high dose of intrathecal pethidine (0.4 mg/kg) is effective in reducing the incidence and intensity of shivering associated with spinal anesthesia for cesarean delivery, but there was a high incidence of nausea and vomiting. Moreover, Khan et al.  also do not recommend the use of intrathecal meperidine (12.5 or 25 mg) for caesarean section during spinal anesthesia for the prevention of shivering, as the use was associated with increased incidence of nausea and vomiting.
Honarmand et al.  found that using higher doses of intrathecal pethidine (0.3 mg/kg) was more effective than using lower doses of pethidine (0.1 and 0.2 mg/kg) in reducing the incidence and severity of shivering during spinal anesthesia with no significant hemodynamic changes on using higher doses of intrathecal pethidine.
In contrast, Zabetian et al.  and Shami et al.  concluded that using a minidose of intrathecal pethidine (10 mg) can decrease the incidence and intensity of shivering during cesarean section under spinal anesthesia without having major side effects.
| Conclusion|| |
The effect of intrathecal nalbuphine is comparable with the effect of intrathecal pethidine in preventing postspinal shivering in patients undergoing knee arthroscopy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Crowley LJ, Buggy DJ. Shivering and neuraxial anesthesia. Reg Anesth Pain Med 2008; 33:241–252.
De Witte J, Sessler DI. Perioperative shivering: physiology and pharmacology. Anesthesiology 2002; 96:467–484.
Bhattacharya P, Bhattacharya L. Postanaesthetic shivering (PAS): a review. Indian J Anaesth 2003; 47:88–93.
Buggy DJ, Crossley AW. Thermoregulation mild perioperative hypothermia and postanesthetic shivering. Br J Anaesth 2000; 84:615–628.
Alfonsi P. Postanesthetic shivering: epidemiology, pathophysiology, and approaches to prevention and management. Drugs 2001; 61:2193–2205.
Sessler DI. Complications and treatment of mild hypothermia. Anesthesiology 2001; 95:531–543.
Katyal S, Tewari A. Shivering: anaesthetic considerations. J Anaesth Clin Pharmacol 2002; 18:363–376.
Kranke P, Eberhart LH, Roewer N, Tramèr MR. Pharmacological treatment of postoperative shivering: a quantitative systematic review of randomized controlled trials. Anesth Analg 2002; 94:453–460.
Park SM, Mangat HS, Berger K, Rosengart AJ. Efficacy spectrum of antishivering medications: meta-analysis of randomized controlled trials. Crit Care Med 2012; 40:3070–3082.
Wrench IJ, Cavill G, Ward JE, Crossley AW. Comparison between alfentanil, pethidine and placebo in the treatment of post-anaesthetic shivering. Br J Anaesth 1997; 79:541–542.
Honarmand A, Safavi MR. Comparison of prophylactic use of midazolam, ketamine, and ketamine plus midazolam for prevention of shivering during regional anesthesia: a randomized double-blind placebo controlled trial. Br J Anaesth, 2008; 101:557–562.
Wadhwa A, Sengupta P, Durrani J, Akça O, Lenhardt R, Sessler DI, Doufas AG. Magnesium sulphate only slightly reduces the shivering threshold in humans. Br J Anaesth 2005; 94:756–762.
Terasako K, Yamamoto M. Comparison between pentazocine, pethidine and placebo in the treatment of post-anesthetic shivering. Acta Anaesthesiol Scand 2000; 44:311–312.
Kelsaka E, Baris S, Karakaya D, Sarihasan B. Comparison of ondansetron and meperidine for prevention of shivering in patients undergoing spinal anesthesia. Reg Anesth Pain Med 2006; 31:40–45.
Fournier R, Van Gessel E, Mackary M, Gamulin Z Onset and offset of intrathecal morphine versus nalbuphine for postoperative pain relief after total hip replacement. Acta Anaesthesiol Scand 2000; 44:940–945.
Tiwari AK, Tomar GS, Agrawal J. Intrathecal bupivacaine in comparison with a combination of nalbuphine and bupivacaine for subarachnoid block: a randomized prospective double-blind clinical study. Am J Ther 2013; 20:592–595.
Badjatia N, Strongilis E, Gordon E, Prescutti M, Fernandez A, Buitrago M et al.
Metabolic impact of shivering during therapeutic temperature modulation, the bedside shivering assessment scale. Stroke 2008; 39:3242–3247.
De Figueiredo Locks G. Incidence of shivering after cesarean section under spinal anesthesia with or without intrathecal sufentanil: a randomized study. Rev Bras Anestesiol 2012; 62:676–684.
Haque MF, Rashid MH, Rahaman MS, Islam MR. Comparison between tramadol hydrochloride & nalbuphine hydrochloride in the treatment of per-operative shivering after spinal anaesthesia. Mymensingh Med J 2011; 20:201–205.
Wang JJ, Ho ST, Lee SC, Liu YC. A comparison among nalbuphine, meperidine, and placebo for treating postanesthetic shivering. Anesth Analg 1999; 88:686–689.
Eskandr AM, Ebeid AM. Role of intrathecal nalbuphine on prevention of postspinal shivering after knee arthroscopy. Egypt J Anaesth 2016; 32:371–374.
Chen JC, Hsu SW, Hu LH, Hong YJ, Tsai PS, Lin TC et al.
Intrathecal meperidine attenuates shivering induced by spinal anesthesia. Ma Zui Xue Za Zhi 1993; 31:19–24.
Roy JD, Girard M, Drolet P. Intrathecal meperidine decreases shivering during cesarean delivery under spinal anesthesia. Anesth Analg 2004; 98:230–234.
Chun DH, Kil HK, Kim HJ, Park C, Chung K-H. Intrathecal meperidine reduces intraoperative shivering during transurethral prostatectomy in elderly patients. Korean J Anesthesiol 2010; 59:389–393.
Anaraki AN, Mirzaei K. The effect of different intrathecal doses of meperidine on shiverering during delivery under spinal anesthesia. Int J Prev Med. 2012; 3:706–712.
Khan ZH, Zanjani AP, Makarem J, Samadi S. Antishivering effects of two different doses of intrathecal meperidine in caesarean section: a prospective randomised blinded study. Eur J Anaesthesiol 2011; 28:202–206.
Honarmand A, Safavi MR, Dadkhah S, Amoushahi M. The effects of different doses of intrathecal meperidine on the incidence and severity of shivering during lower extremity orthopedic surgery under spinal anesthesia: a randomized, placebo-controlled, double blind-clinical trial. Adv Biomed Res 2015; 4:3.
Zabetian H, Jahromi AS, Karami MY, Ghobadifar MA. Antishivering effect of low dose meperidine in caesarean section under spinal anesthesia: a randomized double-blind placebo-controlled trial. Int J Pharmacol 2013; 9:305–311.
Shami S, Nasseri K, Shirmohammadi M, Sarshivi F, Ghadami N, Ghaderi E et al.
Effect of low dose of intrathecal pethidine on the incidence and intensity of shivering during cesarean section under spinal anesthesia: a randomized, placebo-controlled, double-blind clinical trial. Drug Des Devel Ther 2016; 10:3005–3012.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]