Progress in shivering control

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Abstract

Hypothermia is a potent neuroprotectant and induced hypothermia holds great promise as a therapy for acute neuronal injury. Thermoregulatory responses, most notably shivering, present major obstacles to therapeutic temperature management. A review of thermoregulatory physiology and strategies aimed at controlling physiologic responses to hypothermia is presented.

Introduction

Hypothermia is a potent neuroprotectant and therapeutic hypothermia holds great promise in the management of patients with acute cerebral injury. Furthermore, hyperthermia is deleterious to acutely injured brain and treatment of fever may improve clinical outcomes. The application of cooling therapy is complicated by normal thermoregulatory responses including vasoconstriction and shivering. These responses, in particular shivering, must be overcome for therapeutic hypothermia to become practical.

Section snippets

Physiology and pathophysiology of thermoregulation

In humans, core temperature is normally maintained within a tight range (36.5 °C–37.5 °C) known as the “interthreshold range” or “thermoneutral zone.” Core temperatures above or below this range trigger thermoregulatory responses such as vasoconstriction and shivering with lower and vasodilation and sweating with higher core temperatures. The core temperature triggering each thermoregulatory response is known as the threshold. Thermoregulatory control involves the interplay between peripheral

Anesthetics

General anesthesia markedly impairs normal control of body temperature, affecting both warm and cold thermoregulatory responses such that the interthreshold range is increased from approximately 0.4 °C to 4.0 °C [18]. Thermoregulatory thresholds are lowered more in the elderly (60–80 yr) than in younger patients by as much as 1 °C [15].

Anesthetic agents can be divided into thermogenesis inhibitors and thermogenesis non-inhibitors based on their effect on norepinephrine induced thermogenesis.

Non-pharmacologic inhibition of shivering

A number of non-pharmacologic measures have also been used to control shivering. These range from physiologic maneuvers to skin warming devices, as described below.

Relevance of available data to clinical practice

Clinical experience with therapeutic hypothermia is relatively limited and translation of available data regarding shivering suppression is difficult. Few studies have investigated the effects of shivering interventions using clinically available methods to induce and maintain therapeutic hypothermia (e.g., endovascular or surface cooling). Most data come from studies of postanesthetic shivering or from healthy volunteer models, many of which utilize intravenous cold saline with clamping of

Summary

Thermoregulatory shivering is a major obstacle to therapeutic temperature management. At present, most antishivering regimens are meperidine-based, due to this drug's unique antishivering properties. Unfortunately, fairly high doses of meperidine are required which can lead to sedation, respiratory suppression, and nausea. Combination therapy with additional antishivering agents/interventions holds promise in reducing total meperidine requirements and improving cooling efficiency. Several

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