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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 136-139

Clonidine 0.5 μg/kg intravenous as prevention of shivering after spinal anesthesia in cesarean section


Department of Anesthesiology and Intensive Care, Sanglah Hospital, Bali, Indonesia

Date of Submission17-Mar-2020
Date of Decision13-Apr-2020
Date of Acceptance30-Mar-2020
Date of Web Publication18-Jul-2020

Correspondence Address:
Dr. Teresa Wilfrida Mangkung
Department of Anesthesiology and Intensive Care, Sanglah Hospital, Bali
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/BJOA.BJOA_25_20

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  Abstract 


Shivering is a common complication after spinal anesthesia. Shivering can increase oxygen consumption, increase the risk of hypoxemia, and increase complications after surgery. Shivering can be prevented with pharmacological and nonpharmacological therapy. One of the pharmacological therapies that can be used is clonidine. Clonidine is an α2 agonist that works in changing thermoregulation control and decrease the threshold of vasoconstriction and shivering during hypothermia. Clonidine 0.5 μg/kg intravenous was given before spinal anesthesia in ten cases of cesarean section. Clonidine can be used as the prevention of shivering of spinal anesthesia in 60% of cases with a low incidence of nausea and vomiting.

Keywords: Bupivacaine, cesarean section, clonidine, shivering, spinal anesthesia


How to cite this article:
Mangkung TW, Parami P, Budiarta I G, Agung Senapathi TG. Clonidine 0.5 μg/kg intravenous as prevention of shivering after spinal anesthesia in cesarean section. Bali J Anaesthesiol 2020;4:136-9

How to cite this URL:
Mangkung TW, Parami P, Budiarta I G, Agung Senapathi TG. Clonidine 0.5 μg/kg intravenous as prevention of shivering after spinal anesthesia in cesarean section. Bali J Anaesthesiol [serial online] 2020 [cited 2020 Aug 3];4:136-9. Available from: http://www.bjoaonline.com/text.asp?2020/4/3/136/290089




  Introduction Top


Shivering is a common complication after anesthesia. Shivering is a syndrome of involuntary oscillatory contraction of skeletal muscle and physiological response to cold exposure and our body's mechanism to preserve heat from peripheral vasoconstriction.[1] Shivering can increase oxygen consumption, increase the risk of hypoxemia, and increase complications after surgery.[1],[2] Shivering is usually induced by hypothermia, but in some cases, it can happen in normothermia patients perioperatively. The etiology of shivering is unknown, and the gold standard to manage and prevent shivering has not been found. The definition of shivering is fasciculation from face, jaw, or head, or muscle hyperactivity ≥15 s. The current meta-analysis stated that shivering has a higher incidence in female rather than male patients.[1] The incidence of shivering after regional anesthesia is 40%–60% and 37%–57% after spinal anesthesia in cesarean section.[3]

Shivering can be prevented with pharmacologic and nonpharmacologic therapy.[1],[2] Pharmacological therapy that is effective in preventing and managing shivering after spinal anesthesia is opioid α2 agonist, anticholinergic, central nervous system stimulant, and corticosteroid.[1] Park et al.,[4] in their meta-analysis, found that clonidine, meperidine, tramadol, nefopam, and ketamine have good pharmacological effects in treating shivering after anesthesia.

α2 adrenergic agonist receptors such as clonidine can decrease sympathetic activity and central regulation of vasoconstrictor tone that can be used as prevention of shivering after anesthesia. Clonidine can be given in many ways. It can be administered orally or intravenously before or during the surgery.[1] This receptor also can cause sedation, analgesia, and hypotension.[5] The administration of clonidine can lower the incidence of nausea and vomiting during spinal anesthesia.[2] The variety effect of clonidine makes this agent valuable to be used not only as a prevention of shivering but also to overcome other side effects of spinal anesthesia.


  Case Reports Top


In this study, we gave clonidine to ten female pregnant patients who would undergo cesarean section at Sanglah Hospital with spinal anesthesia as shivering prevention after spinal anesthesia. Patients with hypotension (mean arterial pressure below 65 mmHg), antepartum bleeding, heart problem, and allergic with clonidine were excluded from the study. All the patients were given 500 ml crystalloid before spinal anesthesia. Clonidine was given 0.5 μg/kg intravenously 5 min before the injection of bupivacaine 0.5% heavy 12.5 mg intrathecally. Spinal anesthesia was given in L3-L4 with spinal needle G27.

After the injection, we used a skin prick test to measure the level of the sensory blockade and asked the patient to move their lower extremities to measure the Bromage score. The onset of sensory blockade reached Th10, and the motor blockade in Bromage 2 was observed. Hemodynamic was measured before spinal anesthesia at 0, 5, 10, and 15 min after spinal anesthesia. We also used a blanket as a nonpharmacologic shivering prevention measure. We then observed the incidence of shivering, nausea, and vomiting during surgery. After the surgery, the duration of sensory blockade until L1 and to motor blockade Bromage 0 was observed.

Case 1

A 37-year-old female with a pregnancy with preeclampsia was planned for cesarean section. The patient was 80 kg before pregnancy. Five min after spinal anesthesia was given, the patient had hypotension with a blood pressure of 85/43 mmHg and ephedrine was given to increase the blood pressure. Shivering was not happened in this case.

Case 2

A 37-year-old female had pregnancy with preeclampsia and history of cesarean section was planned for cesarean section. The patient was 70 kg before pregnancy. The decrease of mean arterial pressure 5 min after spinal block was ≥20% from the mean arterial pressure before the surgery. The patient did not experience shivering throughout the surgery.

Case 3

A 27-year-old female who had pregnancy with preeclampsia was planned for cesarean section. The patient was 54 kg before pregnancy. Decrease of mean arterial pressure 5 min after spinal block was ≥20% from the mean arterial pressure before the surgery. The patient had shivering after the spinal block. The patient had nausea and vomited in the operating room.

Case 4

A 32-year-old female with superimposed preeclampsia and obesity Grade 1 was planned for cesarean section. The patient was 107 kg before the pregnancy. Blood pressure was stable during the surgery and the patient did not experience shivering after the spinal block.

Case 5

A 30-year-old female had cesarean section due to oligohydramnios. The patient was 64 kg before pregnancy. The patient had hypotension 5 min after spinal block with a blood pressure of 85/50 mmHg and was given ephedrine to increase the blood pressure. The patient had nausea and slept in the operating room. The patient had shivering after the spinal block.*

Case 6

A 36-year-old female had premature contraction, and fetus position was transverse. The patient was planned for cesarean section. The patient was 49 kg before pregnancy. Blood pressure was stable during the surgery. The patient had nausea and vomited in the operating room. The patient had shivering after the spinal block.

Case 7

A 36-year-old female had pregnancy with preeclampsia and obesity Grade 1. The patient was 107 kg before pregnancy. The patient was planned for cesarean section. Decrease of mean arterial pressure was ≥20% in 0 minute after the spinal block. The patient slept during the surgery. The patient did not experience shivering throughout the surgery.

Case 8

A 39-year-old female had pregnancy with cephalopelvic disproportion, history of cesarean section, and fetal congenital anomaly. The patient was planned for cesarean section. The patient was 40 kg before pregnancy. Blood pressure was stable throughout the surgery. Shivering was not happened in this case.

Case 9

A 23-year-old female with preeclampsia was planned for cesarean section. The patient was 48 kg before pregnancy. Blood pressure was stable during the surgery. The patient had shivering in the operating room.

Case 10

A 33-year-old female was in labor with transverse position. The patient was planned for cesarean section. The patient was 70 kg before pregnancy. Five min after the spinal block, the patient had hypotension with a blood pressure of 80/40 mmHg, and ephedrine was given to increase the blood pressure. The patient had nausea and slept during the surgery. Shivering was not happened in this case.


  Discussion Top


The temperature regulating system is divided into three parts: thermosensors and afferent neural pathways, integration systems of thermal inputs, and effector pathways (autonomic and behavioral). The lateral spinothalamic tract is the main afferent pathway with projection into the hypothalamic regulatory center and nuclei in the pons and midbrain. Neural transmission's modulation is nucleus raphe magnus as inhibitor and locus subcoeruleus as a facilitator. The efferent pathway starts at the hypothalamus and makes multiple connections with the reticular formation in the midbrain, pons, and medulla and ends at alpha-motor neurons. The main reactions from hypothermia activated by efferent pathways are vasoconstriction, nonshivering thermogenesis, and shivering. Shivering causes oscillatory and involuntary muscle contraction that increases metabolic heat production, oxygen consumption until 200%–500%, and carbon dioxide production.[4],[6],[7] This condition can cause an increase in the left ventricular systolic work index.[7]

The mechanism of shivering postspinal anesthesia is still unknown. The possible mechanism for shivering in pregnant women after anesthesia is a disturbance of thermoregulation. Shivering to justify a response of thermoregulatory from hypothermia during surgery with tonic or clonic patterns.[7] Spinal anesthesia induces hypothermia that causes shivering by several mechanisms. Spinal anesthesia redistributes heat and core temperature from central to peripheral. After spinal anesthesia, vasoconstriction below the spinal blockade level is lost and can induce hypothermia. The increase in heat loss during surgery also induce hypothermia and shivering.[3]

Shivering management can be used in pharmacological and nonpharmacological management. One of the pharmacological agents that can be used in shivering is clonidine.[7] Clonidine is α2 agonist that works in changing thermoregulation control and decrease the threshold of vasoconstriction and shivering during hypothermia. Clonidine gives anti-shivering effect through the hypothalamus adrenoceptor that can create hyperpolarization of neurons by increasing the conduction of potassium through G protein and causing decrease temperature sensitivity or shivering threshold.[3]

Previous studies stated that clonidine could be used as prevention of shivering after spinal anesthesia.[2],[3],[8],[9] In this study, all the patients used a blanket as nonpharmacologic management and clonidine as pharmacologic management. Shivering could be prevented in 60% of cases in this study [Figure 1]. Four patients had clonidine below 30 μg based on their initial weight before pregnancy, and three of them had shivered. This result needs further study to find the minimum dose of clonidine to prevent shivering or whether the weight has a correlation with the incidence of shivering. Two from six patients with a decrease in blood pressure experienced shivering during surgery. This result showed that low blood pressure did not increase the risk of shivering. Two shivering patients had American Society of Anesthesiologists (ASA) Class 2, and the others had ASA class 3. Shivering can happen in all ASA classes.
Figure 1: Incidence of shivering

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Clonidine is used to lower the blood pressure, and this condition has a synergistic effect with bupivacaine. Administration of clonidine can increase the risk of hypotension in patients under spinal anesthesia. In this study, six patients experienced a decrease of blood pressure ≥20% from the basal blood pressure, with three of them had mean arterial pressure below 65 mmHg and given ephedrine. Four patients with a decrease of blood pressure ≥20% had preeclampsia, and only one of them reached mean arterial pressure below 65 mmHg and given ephedrine. The incidence of hypotension with mean arterial pressure below 65 mmHg was higher in patients without preeclampsia. Patients with preeclampsia had lower incidence mean arterial pressure below 65 mmHg because their basal blood pressure was higher. Clonidine 0.5 μg/kg can cause hypotension in a patient with and without preeclampsia.

Other side effect of spinal anesthesia, such as nausea and vomiting, were found. Nausea happened in 40% of cases and vomiting in 20% of cases. While the sedation effect of clonidine happened in 30% of cases. Clonidine 0.5 μg/kg can be used as the prevention of nausea and vomiting. The low-sedation effect of clonidine made it possible for the early breastfeeding initiation.

Sethi et al.[10] found that the onset of the sensory blockade with clonidine 1 μg/kg intravenous can be reached in 2.56 min, and motor blockade can be achieved in 4.64 min. The duration of the sensory blockade was 141.66 min, and the duration of motor blockade was 223.12 min. Jagadale and Kelkar[11] found that clonidine can prolong the duration of sensory and motor blockade. The duration of the sensory blockade with clonidine 2 μg/kg intravenous was 270 min and duration of 243 min. However, in the control group with normal saline, the duration of sensory blockade was 222 min with motor blockade was 208 min.[11] In this study, the onset time of sensory blockade was achieved in 4.7 min and motoric blockade in 2.4 min. The duration of the sensory blockade in this study was 158 min, and motor blockade was 203 min. The onset time of bupivacaine in this study was similar to the previous study by Sethi et al.[10] with a lower dose of clonidine.


  Conclusion Top


In this case series, clonidine can prevent shivering after spinal anesthesia in cesarean section.

Declaration of patient consent

The authors certify that they have obtained all appropriate consent from the patient for possible future publication. The patients understand that their names and initials will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Suyasa IK, Ryalino C, Pradnyani NP. Dexmedetomidine provides better hemodynamic stability compared to clonidine in spine surgery. Bali J Anesthesiol 2018;2:90-4.  Back to cited text no. 1
    
2.
Aryabiantara IW, Sinardja IK, Sutawan IB, Sinardja CD, Parami P, Ryalino C, et al. Perioperative effects of co-administration of TCI propofol combined with clonidine and ketamine. Bali J Anesthesiol 2018;2:51-55.  Back to cited text no. 2
    
3.
Thockhom RS, Binarani M, Singh HK, Singh TH, Praneshwari S. A comparative study of dexmedetomidine and clonidine in post spinal anaesthesia shivering. J Dent Med Sci 2018;17:15-20.  Back to cited text no. 3
    
4.
Park B, Lee T, Berger K, Park SM, Choi KE, Goodsell TM, et al. Efficacy of nonpharmacological antishivering interventions: A systematic analysis. Crit Care Med 2015;43:1757-66.  Back to cited text no. 4
    
5.
Sear JW. Antihypertensive drugs and vasodilator. In: Hemmings HC, Egan TD, editors. Pharmacology and Physiology for Anesthesia: Foundations and Clinical Application. Philadelphia: Elsevier; 2013. p. 405-25.  Back to cited text no. 5
    
6.
Locks GF. Incidence of shivering after cesarean section under spinal anesthesia with or without intrathecal sufentanil: A randomized study. Rev Bras Anesthesiol 2012;62:676-84.  Back to cited text no. 6
    
7.
Manouchehrian N, Mohammadian A, Jahrami MS, Tazehkand NF, Sanatkar M. A Comparison of the theraupeutic effect of tramadol and meperidine for treatment of shivering after spinal anesthesia in elective caesarean section. Arch Anesthesiol Crit Care 2015;1:50-4.  Back to cited text no. 7
    
8.
Morsali SF, Movasseghi G, Kiaee MM, Ghorbanloo M, Mohaghegh MR, Morsali A, et al. Clonidine versus tramadol for postanaesthetic shivering: A randomized clinical trial study. Biomed Res Ther 2017;4:1716-32.  Back to cited text no. 8
    
9.
Attal P, Chhaya A, Singh T, Upadhayaya R. Comparison of clonidine and tramadol for the control of shivering under spinal anesthesia. Int J Biomed Adv Res 2015;6:25-31.  Back to cited text no. 9
    
10.
Sethi C, Pandey S, Kumar R, Jain A, Sehgal A, Patel S, et al. A comparative evaluation of intravenous dexmedetomidine and clonidine as premedication for prolongation of bupivacaine subarachnoid block for lowe limb orthopaedic surgery. J Evolutions of Med Dent Sci 2015;4:7839-47.  Back to cited text no. 10
    
11.
Jagadale SP, Kelkar VS. Intravenous dexmedetomidine vs. intravenous clonidine to prolong bupivacaine spinal anesthesia. J Med Scid Clin Res 2019;7:304-11.  Back to cited text no. 11
    


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