الفهرس 
SPINAL ANETHESIAOnly 14 pages are availabe for public view
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Abstract
Shivering is a common problem faced by an anesthesiologist during intraoperative as well as in postoperative period. It is a frequent, unpleasant, and undesirable complication occurring after sub-arachnoid block (SAB), secondary to vasodilatation as a result of sympathetic blockade. The incidence of shivering has been reported to be about 36-85% after spinal anesthesia. The present study was designed to compare the efficacy of diclofenac sodium and pethidine on reducing postoperative shivering following sub-arachnoid block.
Spinal anesthesia also called spinal block, subarachnoid block, and intrathecal block, It is a form of regional anesthesia involving injection of local anesthetic in subarachanoid space. Subarachnoid (spinal) block is a safe and effective alternative to general anesthesia when the surgical site is located on the lower extremities, perineum.
Shivering is defined as an involuntary, spontaneous, oscillatory mechanical activity of skeletal muscle associated with increased oxygen consumption, this can be as much as 600%.
Amongst the various causes shivering can be divided into thermoregulatory and non thermoregulatory in nature. Thermoregulatory shivering occurs as a consequence of hypothermia, and in order to maintain normothermia, vasoconstriction and shivering occurs. Post anesthesia shivering is predominantly thermoregulatory in nature as a result of the anesthetic induced inhibition of thermal defense mechanisms and subsequent hypothermia.
Prevention of shivering include warming intravenous fluid and blood products. Pharmacological treatment of shivering include opioid as pethidine, tramadol. Fentanyl and morphine or Non opiates as clonidine, doxapram, midazolam.
An ideal anti-shivering drug is not available. Pethidine, is considered by many authors as the gold standard anti-shivering drug. It is estimated to be effective in 80% of cases.
Pethidine is the most widely studied drug in the treatment of post anesthesia shivering. 25mg of pethidine has been found to be an effective antishivering agent when administered intravenously. Pethidine exerts its analgesic effects by acting as an agonist at the μ-opioid receptor. It is moderately lipid soluble and has an onset of action shorter than that of morphine following IM injection. About 70% is protein bound to albumin, lipoprotein and α1-acid glycoprotein.
Diclofenac is a non steroidal anti-inflammatory drug (NSAID) taken or applied to reduce inflammation and as an analgesic reducing pain in certain conditions.
Many studies have been carried out trying to find a solution for shivering through pharmacological and non pharmacological methods.
There are some studies were done about using diclofenac sodium in shivering management to avoid the side effect of narcotics that used in case of shivering.
The purpose of writing this article is to determine the efficacy of diclofenac sodium in management of shivering and comparing diclofenac sodium with pethidine in controlling shivering.
Study design and sampling
The study was a randomized, prospective, double-blind, placebo-controlled study. The study was conducted on 90 randomly chosen patients after approval of the medical ethical committee. They were allocated in three groups of 30 patients each:
group D
Patients (n=30) of this group received spinal anesthesia and then after shivering occurred, patient received intravenous infusion of diclofenac sodium 1 mg/kg (maximally 75 mg) diluted to 50 ml in dextrose 5% given over 10 minutes.
group P
Patients (n=30) of this group received spinal anesthesia and then after shivering occurred, patient received intravenous infusion of pethidine 0.35 mg/kg diluted to 50 ml in dextrose 5% given over 10 minutes.
group C
Patients (n=30) of this group received spinal anesthesia and then after shivering occurred, patient received intravenous infusion of dextrose 5% given over 10 minutes.
The three groups were adequately monitored and assessed intra- and post-operatively and they were compared as regards grade of shivering and response of shivering to the treatment. Hemodynamic data were also assessed every 5 minute up to 45 minute.
In the current study, shivering was noted in all patients included in the study with different grades. There were statistically significant increase in the incidence of response in P group in treatment of shivering than the two other groups with p-value < 0.001 while no statistically significant difference found between the three studied groups as regards time of response with p-value = 0.084
Pethidine was successful in abolishing post-spinal shivering in 86.7% of cases while diclofenac sodium success in 23.3 % of cases.
In this study, the data show that pethidine infusion is more effective than diclofenac sodium infusion in management of shivering after spinal anesthesia. However diclofenac sodium is better than placebo in a non significant way. Another study with higher sample size and higher dose of diclofenac sodium is needed to check the efficacy of the diclofenac sodium as anti shivering drug.