Comparative efficacy of intravenous tramadol and traditional blanket coverage in managing postoperative shivering among post-spinal anesthesia patients

Sara A. Hwisa 1, Ghada Rajab Alnaeli 2, Aboajela Ramadan Imbark Ajaj 3, Mofeda M. Faraj 4, Dalal Salem Emhamed Almghairbi 5, Kareemah Ali Omar Alhuwayj 6, Lubnah Abdulsalam Mohammed 7
Author affiliations:
  1. Sara Abdurhman Hwisa, Assistant Professor, Department of Medical & Basic Sciences, Faculty of Dentistry and Oral Surgery- Surman, Sabratha University, Libya; E-mail: sara.ab.mu.hw@gmail.com; {ORCID: 0009-0005-1900-8453}
  2. Ghada Rajab Alnaeli, Assistant Professor, Department of Anesthesia, Faculty of Medical Technology, Surman, Sabratha University, Libya; E-mail: ghada.alnaeli@sabu.edu.ly; {ORCID: 0009-0004-8736-468X}
  3. Aboajela Ramadan Imbark Ajaj, Assistant Professor, Department of Anesthesia, Faculty of Medical Technology, Surman, Sabratha University, Libya; E-mail: abogilaa2009@yahoo.com
  4. Mofeda M Faraj, Lecturer, Department of Medical Laboratory Technology, Faculty of Health Sciences Zawia University, Libya; E-mail: mofedahamedan@gmail.com; {ORCID: 0009-0009-9488-0574}
  5. Dalal Salem Emhamed Almghairbi, Assistant Professor, Department of Anesthesia, Faculty of Medical Technology - Zawia University, Libya; E-mail: D.almghairbi@zu.edu.ly
  6. Kareemah Ali Omar Alhuwayj, Lecture, Department of Anesthesia, Faculty of Medical Technology, Surman, Sabratha University, Libya; E-mail: Krymhalhwyj@gmail.com; {ORCID: 0009-0008-9713-1598}
  7. Lubnah Abdulsalam Mohammed, Lecturer at Department of Physics- Faculty of Education, Zawia University, Libya; E-mail: I.abdullah@zu.edu.ly
Correspondence: Sara A. Hwisa; E-mail: sara.ab.mu.hw@gmail.com 
Ghada Rajab Alnaeli; E-mail: ghada.alnaeli@sabu.edu.ly / Medododi01@gmail.com
 

ABSTRACT

 

Background & Objective: Shivering after general as well as spinal anesthesia is a common phenomenon. Unmanaged post-anesthetic shivering can worsen postoperative pain and patient’s metabolism. Various techniques including inj. tramadol, body warming, and covering have been evaluated to treat this common complication. We aimed to compare the effectiveness of tramadol administration with patient coverage as therapeutic methods for managing post-anesthesia shivering.

Methodology: The study enrolled 60 patients who underwent spinal anesthesia. Patients were divided into two groups: Group A received blanket coverage as treatment for shivering, while Group B received intravenous tramadol. Shivering onset time and duration after treatment were measured. Descriptive statistics and chi-square test/independent t-test determined significance, with P < 0.05 considered statistically significant.

Results: The findings of this study revealed no significant difference in the onset of shivering between patients who received intravenous tramadol and those who were covered by blankets (39.83 ± 13.21 min vs 38.60 ± 13.48 min). However, the duration of shivering after treatment was significantly shorter in patients who received intravenous tramadol compared to those who received blanket, e.g., 20.30 ± 9.62 vs. 34.83 ± 12.53; P < 0.000).

Conclusion: In conclusion, intravenous tramadol is more effective than non-pharmacological methods (blankets) in managing shivering. Tramadol treatment resulted in a significantly shorter duration of shivering.

Keywords: Postoperative Shivering; Hypothermia; Spinal Anesthesia; Tramadol; Blanket

Citation: Hwisa SA, Alnaeli GR, Ajaj ARI, Faraj MM, Almghairbi DSE, Alhuwayj KAO, Mohammed LA. Comparative efficacy of intravenous tramadol and traditional blanket coverage in managing postoperative shivering among post-spinal anesthesia patients. Anaesth. pain intensive care 2024;28(5):922−926; DOI: 10.35975/apic.v28i5.2565
Received: May 28, 2024; Reviewed: June 03, 2024; Accepted: Jun 18, 2024

 

1. INTRODUCTION

 

Postoperative shivering following anesthesia leads to an increased metabolic demand, which is directly influenced by the amount of muscle mass engaged and the cardiac status of the patient. The primary approach to prevention involves actively rewarming the patient to avoid preoperative hypothermia. Rapid postoperative skin surface rewarming is an effective method to achieve the shivering threshold temperature, thereby elevating the skin temperature and enhancing patient comfort. However, it is comparatively less effective than certain medications such as meperidine, clonidine, or tramadol, which work by lowering the threshold temperature for shivering.1,2
Both pain and temperature signals are conveyed through comparable fiber systems that intersect at the dorsal horn regions. The rostral ventromedial medulla plays a crucial role in regulating analgesic responses to noxious stimuli and exhibits a thermoregulatory reaction to peripheral warming and cooling. One significant function of the rostral ventromedial medulla is to modulate the quantity of pain and temperature input ascending from the spinal cord by controlling the transmission of neuronal signals at the level of the dorsal horns.3
Shivering can also be linked to heightened adrenergic and sympathetic hyperactivity, leading to potential organ dysfunction, including myocardial ischemia. Moreover, shivering can result in patient discomfort and raise the risk of postoperative complications, such as infection, pain, and bleeding.4,5
Shivering has been observed to potentially contribute to delayed wound healing and an extended hospital stay. The increased metabolic demand may be dangerous for patients with pre-existing conditions such as intrapulmonary shunts, fixed cardiac output, or limited respiratory reserve. However, due to the age-related impairment of normal thermoregulatory control, shivering is infrequent among elderly patients.6
Shivering is recognized as a significant and prevalent concern for patients, given its association with heightened pain levels at the surgical site, increased metabolic demands, elevated oxygen consumption, and compromised hemostasis if not addressed. We assessed the effectiveness of intravenous administration of tramadol and the use of blankets, in the prevention of shivering following anesthesia.7
 

2. METHODOLOGY

 

Demographic data, including gender, age, weight and any previous surgery, was recorded in case of all patients. A descriptive analytical cross-sectional method was used for this study. The study was conducted from June 4, 2023 to November 16, 2023, and involved 60 adult patients who underwent elective surgical procedures.

Preoperative temperature was recorded for every patient. All patients were administered spinal anesthesia with bupivacaine 0.5% heavy 2-3 mL using a needle size ranging from 25 to 27 G. Intravenous fluids were infused at a controlled room temperature of 24°C-26°C, while patients were provided with a single standard blanket to ensure warmth and comfort. The type and the temperature of fluids infused were noted.

Time to onset of shivering after the surgery and the total time of continued shivering were noted. Patients’ temperature, before, during and after the operation was noted.

For prevention of postoperative shivering, two distinct treatment approaches were implemented.  In Group A (30 patients) was treated with blankets, and Group B (30 patients) was injected inj. tramadol 1 mg/kg IV preemptively. The study sought to evaluate various parameters and their mean values, standard deviations, and p-values to determine the potential benefits of each treatment approach.

Statistical analysis
The statistical analysis was conducted using IBM SPSS version 21. The mean time of shivering was calculated for the two treatments to evaluate the differences between the two groups. An independent t-test was used to compare the means of the two groups. A P < 0.05 was considered statistically significant, indicating the presence of a significant difference between the treatments.

 

3. RESULTS

 

The demographic profile and type of operative procedures were consistent across all the groups as depicted in Table 1.

The results presented in Table 2 provide comparative effectiveness of two treatments for shivering: intravenous tramadol and traditional blanket coverage.

 

4. DISCUSSION

 

Regarding the treatment of shivering, intravenous tramadol proved effective in 46.7% among male patients, whereas the use of a blanket resulted control of shivering in 23.3%. It indicates that a higher percentage of male patients were treated for shivering with intravenous tramadol compared to a covered blanket, which is consistent with previous reports.8-10 Conversely, among female patients, 76.7% received shivering treatment with a blanket, while 53.3% received treatment with intravenous tramadol. Despite not finding a significant difference, a higher number of females were treated with the blanket.

 

Table 1: Demographic characteristics of two groups
Items Blanket Group Tramadol Group P – value
Gender Male 7 (23.3) 14 (46.7) 0.058
Female 23 (76.7) 16 (53.3)
Age (y) < 30 10 (33.3) 15 (50.0) 0.683
31-40 10 (33.3) 6 (20.0)
41-50 4 (13.3) 5 (16.7)
51-60 2 (6.7) 2 (6.7)
61-70 3 (10.0) 1 (3.3)
>70 1 (3.3) 1 (3.3)
Weight (kg) 50-60 8 (26.7) 3 (10.0) 0.316
61-70 14 (46.7) 14 (46.7)
71-80 6 (20.0) 9 (30.0)
81-95 2 (6.7) 4 (13.3)
Previous surgery 11 (36.7) 8 (26.7) 0.405
Type of surgery Cesarean section 18 (60.0) 11 (36.7) 0.090
Hernia repair 6 (20.0) 7 (23.3)
Hemorrhoidectomy 4 (13.3) 2 (6.7)
Orthopedic surgery 2 (6.7) 8 (26.7)
Urinary tract operation - 2 (6.7)
IV Fluid type Normal saline 30 (100.0) 24 (80.0) 0.036*
Dextrose saline 0.0 (0.0) 2 (6.7)
Mix (normal saline + blood) 0.0 (0.0) 4 (13.3)
Condition of the IV fluid during operation Room temperature 29 (96.7) 22 (73.3) 0.011*
Warm + Room temp 1 (3.3) 8 (26.7)
Data are n (%). Pearson Chi-Square Test, *: P < 0.05 considered as significant.
 

The age groups with the highest usage of a blanket were < 30 y, with a mean age of 40.07 ± 15.22 years, while the age group in the intravenous tramadol group was < 30 y, with a mean age of 36.47 ± 14.47 y, which is consistent with prior studies,10-13  although another study reported higher ages.8,9 No significant age-related differences in shivering treatment were observed, regardless of whether a blanket or intravenous tramadol was used. Moreover, the study found that the weight groups with the highest usage in both groups were 61-70 y. The mean weight in the blanket group was 67.27 ± 8.72 kg, while in the intravenous tramadol group, it was 70.53 ± 9.50 kg, which were slightly higher compared to some earlier studies,14, 15,16,17 but similar to some other studies.13,18
In terms of the type of recent operation, there were no differences between the groups. However, the highest incidence of the recent operation type was observed among patients undergoing cesarean section, with 60.0% receiving a blanket, while 36.7% received tramadol treatment.

Another parameter evaluated was the type and volume of fluid or blood administered during the operation. The patients in the blanket group received 1683.33 ± 608.61 ml of normal saline, while the patients in the tramadol group received a volume of 1516.67 ± 533.10 ml, demonstrating a significant difference (P = 0.036). Additionally, blood was only administered in the tramadol group. Considering the range of total fluid or blood volume administered during the operation was higher compared to that reported in the prior studies.17,19
 

 Table 2: Parameter comparison in two groups
Items Blanket Group Tramadol Group P – value
Weight (kg) 67.27 ± 8.72 70.53 ± 9.50 0.17
Age (y) 40.07 ± 15.22 36.47 ± 14.47 0.35
Total fluid or blood used during surgery per patient (mL) 1683.33 ± 608.61 1566.67 ± 583.29 0.45
·    Normal saline 1683.33 ± 608.61 1516.67 ± 533.10 0.264
·    Dextrose saline 0.000 ± 0.000 50.00 ± 273.86 -
·    Blood 0.000 ± 0.000 50.00 ± 152.56 -
Onset of the shivering (min) 38.60 ± 13.48 39.83 ± 13.21 0.722
Time period of shivering (min) 34.83 ± 12.53 20.30 ± 9.62 0.000**
Dose of bupivacaine (mL) 2.45 ± 0.20 2.50 ± 0.26 0.411
Temperature, preoperative (oC) 36.63 ± 0.22 36.73 ± 0.29 0.149
Temperature, intraoperative (oC) 36.17 ± 0.30 36.19 ± 0.39 0.794
Temperature postoperative (oC) 35.88 ± 0.35 35.84 ± 0.38 0.728
Data presented as mean ± SD; Independent Samples Test. **: P < 0.05 -considered significant
 

A higher proportion of patients (9.7%) experienced shivering with fluid at room temperature in the blanket group, while the rate was 73.3% with intravenous tramadol treatment as previously reported.21 This significant difference (p = 0.011) suggests that intravenous tramadol may be more effective in reducing shivering under specific fluid conditions.

The study also examined shivering onset and duration. Shivering onset was similar between the blanket group vs the tramadol group (38.60 vs 39.83 minutes), which was higher compared to a prior study,20,22 but without a statistically significant difference. However, the time to stop shivering was significantly less in the tramadol group compared to the blanket group (P < 0.001). The result was higher than what has been reported in earlier studies.14,20,21
The mean bupivacaine volume used was comparable in the two groups with no significant difference.

Regarding the temperature range, before, during, and after the operation, a previous study reported slightly lower temperature ranges than those recorded in this study.17 The mean temperature range before the operation was almost consistent with previous reports.12,14,16,17,23-25 There was no statistically significant difference in the temperature range before, during or after the operation.

 

5. LIMITATIONS

 

This study has a limitation in terms of a small sample size. Furthermore, the focus of the study on a specific patient population and surgical setting may restrict the applicability of the results to other contexts.

 

6. CONCLUSION

 

The intravenous tramadol group exhibited a significantly shorter duration of shivering compared to the blanket group. These findings suggest that intravenous tramadol may be a more effective treatment option to control shivering after surgical procedures compared to merely using a blanket.

7. Data availability
The numerical data generated during this research is available with the authors.\

9. Conflict of interest
The study utilized the hospital resources only, and no external or industry funding was involved.

10. Ethical consideration
All procedures in this study were employed according to the guidelines established by the Department of Anesthesia, Faculty of Medical Technology, Surman and the Declaration of Helsinki. Ethical committee approval was obtained for sample collection in accordance with these guidelines.

11. Authors contribution
All authors made substantial contributions to the acquisition of data, analysis of data, and interpretation of the results. All authors have reviewed and approve the final version of the manuscript submitted for publication.

 

12. REFERENCES

 
  1. Alfonsi P. Postanaesthetic shivering: epidemiology, pathophysiology, and approaches to prevention and management. Drugs. 2001;61(15):2193-205. [PubMed] DOI: 2165/00003495-200161150-00004
  2. Chung SH, Lee BS, Yang HJ, Kweon KS, Kim HH, Song J, et al. Effect of preoperative warming during cesarean section under spinal anesthesia. Korean J Anesthesiol. 2012;62:454–60. [PubMed] DOI: 4097/kjae.2012.62.5.454
  3. Grahn DA, Heller HC. Activity of most rostral ventromedial medulla neurons reflect EEG/EMG pattern changes. Am J Physiol. 1989;257(6 Pt 2):R1496-505. [PubMed] DOI: 1152/ajpregu.1989.257.6.R1496
  4. Choi KE, Park B, Moheet AM, Rosen A, Lahiri S, Rosengart A. Systematic quality assessment of published antishivering protocols. Anesth Analg. 2017;124:1539–46. [PubMed] DOI: 1213/ANE.0000000000001571
  5. Sessler DI, Rubinstein EH, Moayeri A. Physiologic responses to mild perianesthetic hypothermia in humans. Anesthesiology. 1991;75:594–610. [PubMed] DOI: 1097/00000542-199110000-00009
  6. Frank SM, Fleisher LA, Olson KF, Gorman RB, Higgins MS, Breslow MJ, et al. Multivariate determinants of early postoperative oxygen consumption in elderly patients: effects of shivering, body temperature, and gender. Anesthesiology. 1995;83:241–9. [PubMed] DOI: 1097/00000542-199508000-00002
  7. 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(1):40-5. [PubMed] DOI: 1016/j.rapm.2005.10.010
  8. Butt MR, Javed HM, Ashfaq MA, Iqbal A, Zahid MM, Khalid M. Comparison of prophylactic dose of tramadol and dexamethasone in preventing shivering in patients undergoing subarachnoid block. Biol Clin Sci Res J. 2023;2023(1):331. DOI: 54112/bcsrj.v2023i1.331
  9. Avais B, Javed HM, Sheikh NG, Sheikh MG, Jamshaid B, Butt Z. Comparison of ketamine and tramadol for prevention of shivering during spinal anesthesia. Biol Clin Sci Res J. 2022;156. DOI: 54112/bcsrj.v2022i1.156
  10. Haq MU, Ayaz SB, Qureshi S, ur Rehman H, Iftikhar H. Pethidine versus tramadol for post-anaesthetic shivering control in patients undergoing elective surgery under spinal anaesthesia. Pak Armed Forces Med J. 2023;73(2):431-4. DOI: 51253/pafmj.v73i2.8817
  11. Angral R, Wani AA, Kapoor BB. Tramadol and postoperative shivering in patients undergoing open and laparoscopic cholecystectomy under general anaesthesia. South Afr J Anaesth Analg. 2012;18(2). [FreeFullText]
  12. Mohta M, Kumari N, Tyagi A, Sethi AK, Agarwal D, Singh M. Tramadol for prevention of postanaesthetic shivering: a randomised double-blind comparison with pethidine. Anaesthesia. 2009;64(2):141-6. [PubMed] DOI: 1111/j.1365-2044.2008.05711.x
  13. Mathews S, Al Mulla A, Varghese PK, Radim K, Mumtaz S. Postanaesthetic shivering--a new look at tramadol. Anaesthesia. 2002;57(4):394-8. [PubMed] DOI: 1046/j.1365-2044.2002.2457_3.x
  14. Waghmare NN, Pande AH, Shivram H. Comparative study of intravenous clonidine versus tramadol for controlling shivering in regional anesthesia for cesarean section. Eur J Mol Clin Med. 2022;9(3):1250-6. [FreeFullText]
  15. Chung JS, Kang K, Kim YJ. Effect of tramadol in the treatment of postanesthetic shivering. Korean J Anesthesiol. 1999;36(6):1003-7. DOI: 4097/kjae.1999.36.6.1003
  16. Mahesh T, Kaparti L. A randomised trial comparing efficacy, onset and duration of action of pethidine and tramadol in abolition of shivering in the intraoperative period. J Clin Diagn Res. 2014;8(11). [PubMed] DOI: 7860/JCDR/2014/10584.5148
  17. Ihn CH, Joo JD, Chung HS, Choi JW, Kim DW, Jeon YS, et al. Comparison of three warming devices for the prevention of core hypothermia and post-anaesthesia shivering. J Int Med Res. 2008;36(5):923-31. [PubMed] DOI: 1177/147323000803600508
  18. Tyvold SS. Preventing hypothermia in outpatient plastic surgery by self-warming or forced-air-warming blanket: a randomised controlled trial. Eur J Anaesthesiol. 2019;36(11):843-50. [PubMed] DOI: 1097/EJA.0000000000001087
  19. Gemechu AD, Gebremedhin TD, Andebiku AA, Solomon F, Sorsa A. Effect of ketamine versus tramadol on prophylactic post-spinal shivering in orthopedic surgery: a prospective cohort study. BMC Anesthesiol. 2022;22(1):361. [PubMed] DOI: 1186/s12871-022-01906-z
  20. Al Maruf A, Islam MS, Hoq N. Effect of tramadol and pethidine on shivering during cesarean section under spinal anaesthesia. J Armed Forces Med Coll Bangladesh. 2015;10(2):27-32. DOI: 3329/jafmc.v10i2.25918
  21. Mamo M, Zema Z, Abera W, Tila M, Darma B, Suileman M, et al. Effect of intravenous tramadol versus pethidine on postspinal shivering control among mothers during cesarean section: a prospective observational cohort study. Ann Med Surg. 2023;85(6):2324-9. [PubMed] DOI: 1097/MS9.0000000000000620
  22. Sattar A, Amin P, Bhatti TK, Ahmad A, Ali T, Chaudhry AR. Compare the effect of addition of low-dose ketamine to tramadol for the prevention of shivering under spinal anesthesia. Pak J Med Health Sci. 2022;16(2):1188-90. DOI: 53350/pjmhs221621188
  23. Onyekwulu FA, Agu EE, Amucheazi AO. Efficacy of intravenous tramadol in the control of shivering following spinal anaesthesia for caesarean section. Niger Postgrad Med J. 2016;23(3):116-20. [PubMed] DOI: 4103/1117-1936.190343
  24. Qona’ah A, Rosuliana NE, Bratasena A, Made I. Management of shivering in post-spinal anesthesia using warming blankets and warm fluid therapy. J Ners. 2020;14(3):305-9. DOI: 20473/jn.v14i3.17166
  25. Yousuf B, Samad K, Ullah H, Hoda MQ. Efficacy of tramadol in preventing postoperative shivering using thiopentone or propofol as induction agent: a randomized controlled trial. J Anaesthesiol Clin Pharmacol. 2013;29(4):521-5. [PubMed] DOI: 10.4103/0970-9185.119166