Prophylactic Intravenous

Paracetamol For Prevention Of

Shivering After General Anesthesia
in Elective Cesarean Section
Ahmadreza S Gholami, Mehdi Hadavi1
Department of Anesthesiology, 1Aja University of Medical
Sciences, Besat Nahaja General Hospital, Tehran, Iran

Oleh: Anna Erliana Oetarman

Pembimbing: dr. Mariza Fitriati, Sp.An
Thermoregulation

 The important mechanisms of heat loss from the body

include: radiation, conduction, convection, and
evaporation.
 Central regulation of body temperature is by feedback
mechanisms that operate predominantly through the
preoptic nucleus of the hypothalamus
 The reflex responses to cold (vasoconstriction,
piloerection, shivering, and nonshivering thermogenesis)
originate in the posterior hypothalamus.
 The hypothalamic thermostat detects body temperature
changes and initiates autonomic, somatic, and
endocrine thermoresponses when the various set points
are reached.
Hypothermia during Labor
 Hormonal factors are likely to influence
thermoregulatory responses during labor and delivery.
Progesterone release during the normal menstrual cycle
is associated with elevated circulating norepinephrine
concentrations, which in turn slightly augment core
temperature.
 Heat loss may be exaggerated if laboring women are
exposed too long to a relatively cool hospital
environment. Clinical interventions, such as intravenous
infusion of cold fluid, can further exacerbate heat loss.

Sumber : Yucel MD et al. SHIVERING and SHIVERING-like Tremor during Labot

with and without epidural analgesia. Anesthesiology 6 1999, Vol.90, 1609-1616.
 Hypothermia during Anesthesia
General anesthesia
 Volatile anesthetics, propofol, and older opioids such as morphine
and meperidine promote heat loss through vasodilation.
 Fentanyl and its derivatives, directly impair hypothalamic
thermoregulation in a dose-dependent manner.
 Opioids also depress overall sympathetic outflow, which further inhibits
any attempts at thermoregulation.
 The depressant effect on the hypothalamus results in an elevated
threshold for heat response, along with a diminished threshold for cold
response such as vasoconstriction and shivering.
 Nitrous oxide depresses thermoregulation to a lesser extent than
equipotent concentration of the volatiles, and midazolam has minimal
or no influence. Presumbaly this would be true for other
benzodiazepines as well.
Hypothermia during Anesthesia
Regional anesthesia
 Hypothermia is very common following spinal and epidural
anesthesia.
 Blockade of afferent fibers from large regions obviously prevents cold
input to the hypothalamus.
 For reasons yet to be explained, the thermoregulatory center
incorrectly judges skin temperature in blocked regions to be
abnormally elevated.
 For reasons yet to be explained, the thermoregulatory center
incorrectly judges skin temperature in blocked regions to be
abnormally.
 Despite this drop in core temperature, patients generally feel warm
because the hypothalamus misinterprets skin temperature. In fact,
patients may become hypothermic enough to commence shivering
despite their subjective feeling of warmth.
 SHIVERING

 Postoperative shivering is a common complication following general

anesthesia and also occurs intraoperatively during moderate and deep
sedation.
 Even a small decrease of 0.5°C may induce shivering.
 Patients often identify feeling cold as one of the most unpleasant aspects of
their treatment, sometimes worse than any pain associated with the
procedure.
 Shivering is not only subjectively unpleasant but is physiologically stressful
because it elevates blood pressure, heart rate, oxygen consumption, and
plasma catecholamine concentrations. Moreover, shivering may aggravate
pain and hinder wound closure by simply stretching surgical incisions.
 Mechanism of Shivering
 Increased neuronal efferent outflow to skeletal muscle and
subsequent feedback oscillations due to muscle spindle
stretch reflexes
 Tremor due to thermogenic shivering is generally tonic
(continuous),
 Cause of this tremor pattern is unclear, but it may result from
anesthetic-induced disinhibition of normal descending
control over spinal reflexes
 It is significant that pain may be a key factor in triggering
tremor in patients who are otherwise normothermic
Management of Shivering

 Forced warming of the patient.

 Use of pharmaceutical agents.
 Pethidine is one of the frequent choices to prevent
postoperative shivering. Complication of pethidine is
respiratory depression (especially in the presence of
previously administered anesthetic drugs), nausea and
vomiting.
PARASETAMOL

 Acetaminophen (paracetamol)
 efective and safe drug for managing mild to moderate
pain
 acts through a centrally mediated prostaglandin
inhibition to decrease the hypothalamic temperature set
point
 Rectal administration of acetaminophen has been
shown to be effective for prevention of shivering in the
therapeutic hypothermia.
PURPOSE

 The aim of this study was to assess the efficacy of

prophylactic paracetamol on postanesthetic shivering.
 There is no study regarding intravenous paracetamol as
a prophylactic agent against postoperative shivering.
MATERIAL AND METHODS

 Prospective randomized double blind trial.

 Sample size of the study was calculated based on a
type I error of 0.05, a study power of 80, and a minimum
difference of 25% in the prevalence of postanesthetic
shivering between the two groups.
 Ethical approval was obtained from the ethical
committee of the University of Medical Sciences.
 110 parturients aged 18–40 years
ASA status I or II
undergoing elective cesarean section

exclusion criteria:
• history of allergy to paracetamol
• cardiopulmonary disease
• Hypertension
• Diabetes
• renal disease (creatinine more than 1.5)
• chronic lung disease
• liver disease
• history of alcohol abuse
• body temperature more than 38°C or less than 36°C

15’after the delivery of the baby

55 parturients 55 parturients
100 ml normal saline 1 gram paracetamol in 100 ml normal saline

Operation room temperature was maintained at 22–24°C.

RSI Thiopental sodium 5 mg/kg

Succinylcholine 1.5 mg/kg Monitoring HR,
BP, SpO2,
EtCO2, Temp
Maintenanc 0.8 MAC isoflurane in 50% oxygen and 50% nitrous
e oxide.
 Atracurium 0.5 mg/kg

After baby birth

Fentanyl 2 μg/kg
Midazolam 0.05 mg/kg
Oxytocin 30 IU were infused

End of operation
Neuromuscular
Blokage Neostigmine 0.04 mg/kg
Reversal Atropine 0.02 mg/kg

Extubasi

Observation 30’
Tsai and Chu methods
SCORE 0 no shivering
SCORE 1 one or more of the following: Piloerection,
peripheral, vasoconstriction, peripheral
cyanosis with no other cause, but no
muscle activity
SCORE 2 implies visible muscular activity confined
to one muscle group
SCORE 3 implies visible muscular activity in more
than one muscle group
SCORE 4 mplies gross muscular activity involving
the whole body

SCORE 3-4 Petidin 25 mg

Rescue
Nausea, vomiting Ondansetron 4 mg
STATISTICAL ANALYSIS

 Data analyses were performed using the Statistical

Package for the Social Sciences (SPSS) version 19.0
 The incidence of shivering and side effects were
compared using t‐test and chi‐square test
 Results were reported as mean ± standard deviation
(SD).
 P value less than 0.05 was considered to be significant.
RESULTS
RESULTS
RESULTS
 DISCUSSION
 Intravenous paracetamol was effective in preventing shivering due to general anesthesia.
 Age, long duration of surgery, cold temperature in the room, and cold fluids infusion, are
risk factors for postoperation shivering
 Paracetamol is a safe and efective analgesic agent for mild to moderate pain.
Intravenous infusion of acetaminophen (paracetamol) results in a rapid elevation in
plasma concentration, approximately within 15–20 min after the injection, which declines
after 4 h.
 In 2010, the Food and Drug Association (FDA) approved the use of intravenous
acetaminophen for the management of pain and fever.
 Mechanism of intravenous acetaminophen may involve central inhibition of COX2,
inhibition of NO generation via blockade of N‐methyl‐D‐aspartate (NMDA) receptors,
activation of descending serotonergic pathways, and inhibition of COX3.
 Serotonergic pathways are part of the descending pain system, activation of serotonergic
pathways plays a key role in the analgesic effect of paracetamol
 Paracetamol acts on the heat‐regulatory center by inhibition of prostaglandin synthesis.
Conversion of paracetamol to N‐arachidonoylphenolamine an endocannabinoid
reuptake inhibitor, appears to be an important in pain control.
 Pertanyaan Klinis
Kritisi Jurnal
 Pada pasien yang dilakukan sectio cessaria apakah parasetamol efektif
sebagai profilaksis shivering

Telusur Jurnal
 PICO

Population Intervention Comparison Outcome

Wanita yang Parasetamol Plasebo Shivering

direncanakan
sectio cessaria
 REQUIRMENT
V
Apakah sampel yang mewakili pasien dimasukkan dalam
A penelitian pada waktu perjalanan penyakitnya sama?
L YA

I
D
I
T
Y
ALLOCATION
Apakah penempatan Intervention dan Control diacak dan disembunyikan? YA
Apakah kelompok-kelompok Intervention dan Control
sebanding pada awal percobaan? YA
MAINTENANCE
Apakah kedua kelompok memperoleh kointervensi yang sama? YA
Apakah ada kecukupan tindak lanjut? YA
Pengukuran apa yang digunakan dan seberapa
dampak perlakuannya?
Mungkinkah dampak terjadi karena kebetulan?

Kecil kemungkinan untuk kebetulan karena menggunakan p< 0,05

untuk perbedaan yang signifikan.
 APPLICABILITY

Apakah PICO jurnal yang diperoleh sesuai PICO pertanyaan klinis? YA

Apakah pasien anda cukup mirip dengan pasien dalam penelitian?
YA
Apakah indeks dalam penelitian ini dapat diterapkan untuk manajemen
pasien di lingkungan anda? YA

Apakah outcomes penelitian ini penting bagi pasien anda? YA

Akankah potensi manfaat lebih besar dibanding potensi merugikan bila
indeks ini diaplikasikan pada pasien anda? YA
Apakah hasil penelitian ini dapat diintegrasikan dengan nilai-nilai serta
harapan pasien anda? YA
 TELAAH JURNAL

JURNAL ini VALID, IMPORTANT dan APPLICABLE

 Nyberg Score
No Kriteria Skor Ket

1 Purpose of the study (tujuan penelitian) 2 Mengetahui efek parasetamol sebagai

Jelas : 2, kurang jelas : 1, tidak jelas : 0 anti shivering

2 Patient selection (seleksi px) 2 Pasien parturient PS ASA 1 dan 2 yang

Jelas : 2, kurang jelas : 1, tidak jelas : 0 akan dilakukan SC elektif

3 Type of trial (tipe penelitian) 2 Parasetamol 1 gram dan Normal saline

Kontrol jelas/adekuat atau kontrol tidak adekuat tapi objektif :
2
Tidak ada kontrol tp perlu u/ cegah bias atau dilakukan
objektif :1
Tidak adekuat / tidak objektif : 0
 Nyberg Score
no Kriteria Skor Ket

4 Design of study (metode penelitian) 1 Double blind

Double blind atau single blind dgn pengukuran efektifitas
secara lab. : 2
Single blind atau non blind dgn pengukuran objektif : 1
Non blind : 0

5 Randomization of patients to treatment (randomisasi) 2 randomisasi dengan komputer

Randomisasi : 2, randomisasi tdk adekuat : 1, tidak
randomisasi : 0

6 Dosage chosen (pemilihan dosis) 1 Dosis yang digunakan sama : Parasetamol

Nilai hanya 1 atau 0. 1 gram
 Nyberg Score
no Kriteria Skor Ket
7 Registration of effect (efektifitas obat) 2 Double blind
Bila dilakukan dgn baik : 2, tidak lengkap : 1, tidak
dilakukan : 0

8 Assessment of side effect ( perhatian ESO) 2 Nausea vomiting

ESO dinyatakan / dilihat di depan/ dipantau/
kesimpulan yg mungkin terjadi : 2
Bila hanya salah satunya saja atau dinyatakan
bahwa ESO tidak ada : 1
Tidak dinyatakan : 0
9 Concurrent drug therapy (keterangan ttg pemberian 1 Tercantum jelas di
obat lain) metode penelitian
Informasi lengkap : 1, tidak ada informasi : 0
no Kriteria Skor Ket

10 Statistical evaluation (penggunaan statistik) 2 SPSS 19,0

Lengkap nama/perhitungan : 2, tidak lengkap : 1,
tidak ada : 0
11 Author’s conclusion ( kesimpulan) 2 Kesimpulan sesuai dengan tujuan
Kesimpulan jelas, sesuai tujuan penelitian, penelitian untuk membuktikan
berdasarkan data : 2
Kurang jelas : 1, kesimpulan tidak berdasarkan
data : 0
Total Skor 19 BAIK

Hasil penilaian menurut Nyberg ini mengelompokkan uji klinik dalam :

Sempurna : skor 20
Baik (sangat baik) : skor 16-19
Cukup : skor 11-15
Kurang : skor kurang dari 10
TERIMA KASIH