Randomized Double Blind Comparison of Prophylactic Tramadol and Tramadol Plus Ketamine for Prevention of Shivering after Spinal Anesthesia in Lower Segment Caesarian Section
DOI:
https://doi.org/10.36570/jduhs.2024.1.2007Keywords:
Cesarean Section, Ketamine, Shivering, Spinal Anesthesia, TramadolAbstract
Objective: To assess the effectiveness of prophylactic intravenous tramadol alone versus a combination of tramadol and ketamine in preventing shivering during spinal anesthesia for lower segment caesarean section.
Methods: This double-blind randomized controlled trial was conducted at Ziauddin Hospital, North Nazimabad, Karachi, Pakistan from August 2023 to October 2023. Pregnant women aged between 18 to 40 years meeting American Society of Anesthesiologist physical status I and II admitted in hospital for lower segment caesarian section were enrolled. One group received an injection tramadol 0.5mg/kg whereas the other group received an injection of tramadol 0.25mg/Kg plus an injection ketamine 0.25 mg/Kg. The primary outcomes were incidence of shivering and severity of shivering. Time to shiver and complications were secondary outcomes.
Results: Of total 190 patients, the mean age was 25.95 ±3.63 years. Shivering was reported in 96 (50.5%) patients. The incidence of shivering was found significantly lower in tramadol plus ketamine group as compared to tramadol group i.e., 18 (18.7%) vs. 78 (81.3%) (p-value <0.001). Severity of shivering was found significantly lower in tramadol plus ketamine group as compared to tramadol group (p-value <0.001). Mean duration of shivering found significantly lower in tramadol plus ketamine group as compared to tramadol group i.e., 4.78 ±0.73 minutes vs. 8.46 ±1.02 minutes (p-value <0.001) respectively.
Conclusion: The incidence of shivering was significantly lower in the group receiving the combination therapy compared to those receiving tramadol alone. Notably, the severity and duration of shivering were also markedly reduced in the tramadol plus ketamine group.
Downloads
References
Amsalu H, Zemedkun A, Regasa T, Adamu Y. Evidence-based guideline on prevention and management of shivering after spinal anesthesia in resource-limited settings: review article. Int J Gen Med 2022; 15:6985-998. doi:10.2147/IJGM.S370439
Sari S, Aksoy SM, But A. The incidence of inadvertent perioperative hypothermia in patients undergoing general anesthesia and an examination of risk factors. Int J Clin Pract 2021; 75:e14103. doi:10.1111/ijcp.14103
Girma T, Alemu W, Assen S. Effect of prophylactic intrathecal pethidine on the incidence of shivering on mothers undergoing cesarean section under spinal anesthesia: a randomized controlled trial. Front Med (Lausanne) 2022; 9:887724. doi:10.3389/fmed.2022.887724
Wodarski B, Chutkowski R, Banasiewicz J, Moorthi K, Wojtowicz S, Malec-Milewska M, et al. Risk factors for shivering during caesarean section under spinal anaesthesia. A prospective observational study. Acta Anaesthesiol Scand 2020; 64:112-6. doi:10.1111/aas.13462
Kumar K, Lin C, Symons T, Railton C. Narrative review on perioperative shivering during caesarean section under neuraxial anaesthesia. Rom J Anaesth Intensive Care 2023; 29:41-6. doi:10.2478/rjaic-2022-0006
Qi X, Chen D, Li G, Cao J, Yan Y, Li Z, et al. Risk factors associated with intraoperative shivering during caesarean section: a prospective nested case-control study. BMC Anesthesiol 2022; 22:56. doi:10.1186/s12871-022-01596-7
Ferede YA, Aytolign HA, Mersha AT. The magnitude and associated factors of intraoperative shivering after cesarean section delivery under Spinal anesthesia': A cross sectional study. Ann Med Surg (Lond) 2021; 72:103022. doi:10.1016/j.amsu.2021.103022
Kang P, Park SK, Yoo S, Hur M, Kim WH, Kim JT, et al. Comparative effectiveness of pharmacologic interventions to prevent shivering after surgery: a network meta-analysis. Minerva Anestesiol 2019; 85:60-70. doi:10.23736/S0375-9393.18.12813-6
Pirenne V, Dewinter G, Van de Velde M. Spinal anaes-thesia in obstetrics. Best Pract Res Clin Anaesthesiol 2023; 37:101-8. doi:10.1016/j.bpa.2023.03.006
Fenta E, Kibret S, Hunie M, TamireT, FentieY, Seid S, et al. The effects of intravenous tramadol vs. intravenous ketamine in the prevention of shivering during spinal anesthesia: A meta-analysis of randomized controlled trials. Front Med (Lausanne) 2022; 9:1011953. doi: 10.3389/fmed.2022.1011953.
Abdelrahman RS. Prevention of shivering during regio-nal anaesthesia: comparison of midazolam, midazolam plus ketamine, tramadol, and tramadol plus ketamine. Life Sci J 2012; 9:132-9. doi:10.7537/marslsj090212.16
Tsai YC, Chu KS. A comparison of tramadol, amitriptyline, and meperidine for postepidural anesthetic shivering in parturients. Anesth Analg 2001; 93:1288–92. doi:10.1097/00000539-200111000-00052
Roofthooft E, Joshi GP, Rawal N, Van de Velde M; PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy and supported by the Obstetric Anaesthetists' Association. PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2021; 76:665-80. doi:10.1111/anae.15339
Mitchell KD, Smith CT, Mechling C, Wessel CB, Orebaugh S, Lim G. A review of peripheral nerve blocks for cesarean delivery analgesia. Reg Anesth Pain Med 2019; :rapm-2019-100752. doi:10.1136/rapm-2019-100752
Fernandes NL, Dyer RA. Anesthesia for urgent cesarean section. Clin Perinatol 2019 ; 46:785-99. doi:10.1016/j.clp.2019.08.010
Van de Velde M. Low-dose spinal anesthesia for cesaran section to prevent spinal-induced hypotension. Curr Opin Anaesthesiol 2019; 32:268-70. doi:10.1097/ACO.0000000000000712
Gomez NA, Warren N, Labko Y, Sinclair DR. Intrathecal opioid dosing during spinal anesthesia for cesarean section: an integrative review. J Dr Nurs Pract 2020; 13:108-19. doi:10.1891/JDNP-D-19-00025
Ferrarezi WP, Braga AF, Fereira VB, Mendes SQ, Brandao MJ, Braga FS, et al. Spinal anesthesia for elective cesarean section. Bupivacaine associated with different doses of fentanyl: randomized clinical trial. Braz J Anesthesiol 2021; 71:642-8. doi:10.1016/j.bjane.2021.03.030
Thakur N, Balachander H, Rudingwa P, Pannerselvam S. Shivering and changes in body temperature in patients undergoing caesarean section under spinal anaesthesia with bupivacaine vs bupivacaine and fentanyl: A randomized clinical study. J Anaesthesiol Clin Pharmacol 2023; 39:67-73. doi:10.4103/joacp.joacp_156_21
Feng G, Wang Y, Feng J, Luo X, Li C, Yao S. The relation-ship between core temperature and perioperative shivering during caesarean section under intrathecal anesthesia with bupivacaine and ropivacaine: a randomized controlled study. J Anesth 2021; 35:889-95. doi:10.1007/s00540-021-02995-9
Subramani Y, Nagappa M, Kumar K, Fochesato LA, Chohan MB, Zhu YF, et al. Effect of intrathecal lipophilic opioids on the incidence of shivering in women undergoing cesarean delivery after spinal anesthesia: a systematic review and bayesian network meta- analysis of randomized controlled trials. BMC Anesthesiol 2020; 20:214. doi:10.1186/s12871-020-01116-5.
Kaur M, Singh PM. Current role of dexmedetomidine in clinical anesthesiaand intensive care. Anesth Essays Res 2011; 5:128-33. doi:10.4103/0259-1162.94750
Karaman S, Gunusen I, Ceylan A, Karaman Y, Cetin EN, Derbent A, et al. Dexmedetomidine infusion prevents postoperative shivering inpatients undergoing gynecologic laproscopic surgery. Turk J Med Sci 2013; 43:232-7. doi:10.3906/sag-1204-80
Bajwa S J, Gupta S, Kaur J, Singh A, Parmar S. Reduction in the incidence of shivering with perioperative dexmedetomidine: a randomized prospectivestudy. J Anaesthesiol Clin Pharmacol 2012; 28:86-91. doi:10.4103/0970-9185.92452
Usta B, Gozdemir M, Demircioglu RI, Muslu B, Sert H, Yaldiz A. Dexmedetomidine for the prevention of shivering during spinal anesthesia. Clinics (Sao Paulo) 2011; 66:1187-91. doi:10.1590/s1807-59322011000700011
Bozgeyik S, Mizrak A, Kilic E, Yendi F, Ugur BK. The effe-cts of preemptivetramadol and dexmedetomidine on shivering during arthroscopy. Saudi J Anaesth 2014; 8:238-43. doi:10.4103/1658-354X.130729
Aroni F, Iacovidou N, Dontas I, Pourzitaki C, Xanthos T. Pharmacological aspects and potential new clinical applications of ketamine: reevaluation of an old drug. J Clin Pharmacol 2009; 49:957-64. doi:10.1177/0091270009337941
De Witte J, Deloof T, De Veylder J, Housemans PR. Tramadolin the treatment of postanaesthetic shivering. Acta Anaesthesiological Scandinavica 1997; 41:506-10. doi:10.1111/j.1399-6576.1997.tb04732.x
Lema GF, Gebremedhn EG, Gebregzi AH, Desta YT, Kassa AA. Efficacy of intravenous tramadol and low-dose ketamine in the prevention of post-spinal anesthesia shivering following cesarean section: a double-blinded, randomized control trial. Int J Womens Health 2017; 9:681-8. doi:10.2147/IJWH.S139655
Published
How to Cite
Issue
Section
License
Copyright (c) 2024 Muhammad Arif, Zeeshan Mirza, Haider Abbas Mandviwala, Sajid Saif, Rabeea Khan, Muhammad Hassam
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Articles published in the Journal of Dow University of Health Sciences are distributed under the terms of the Creative Commons Attribution Non-Commercial License https://creativecommons.org/ licenses/by-nc/4.0/. This license permits use, distribution and reproduction in any medium; provided the original work is properly cited and initial publication in this journal. 
