A study of the incidence of shivering after cesarean section surgery, a comparative study between general and spinal anesthesia

doi:10.21203/rs.3.rs-3890872/v1

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Research Article

A study of the incidence of shivering after cesarean section surgery, a comparative study between general and spinal anesthesia

https://doi.org/10.21203/rs.3.rs-3890872/v1

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Introduction:

Shivering is an involuntary, spontaneous, and repetitive contraction of the skeletal muscle and increases patients’ discomfort, oxygen-consuming, wound infection; increased surgical bleeding, and morbid cardiac events. The aim of this study was to determine the magnitude and associated factors of intraoperative shivering after cesarean sec

Methods and materials:

An institution-based cross-sectional study was conducted. A total of 80 willing patients were included in the study after obtaining ethical consent and we have used consecutive sampling techniques. Axillary temperature was recorded preoperatively and in the intra-operative period every 5 min. Descriptive statistics, cross-tabs, and binary logistic regression analysis were performed to identify the association shivering and independent variables. The strength of the association was presented using an adjusted odds ratio with a 95% confidence interval and a p-value < 0.05 was considered as statistically significant.

Results

In this study, the incidence of intraoperative shivering after cesarean section under spinal anesthesia was similar to several studies [7.5%], the incidence of intraoperative shivering after cesarean section under general anesthesia was [31.3%], hypothermia, and hypotension. Blood pressure, duration of surgery, age, body mass index, and type of anesthesia are factors strongly associated with shivering.

Conclusion

In this study duration of surgery, hypothermia and hypotension were the independent associated risk factors for intraoperative shivering.

Anesthesiology & Pain Medicine

Shivering

Spinal anesthesia

Intraoperative

Incidence

Associated factor

General anesthesia is a medical procedure that aims to relieve the patient's pain and make the patient lose consciousness. The patient also suffers from temporary or reversible memory loss. General anesthesia has three components or the so-called triad of anesthesia, which are sedative or hypnotic, which means making the patient calm or asleep, and analgesia. It means loss of pain sensation, muscle relaxant and means paralysis of skeletal muscles. It is estimated that tens of millions of patients receive general anesthesia during surgery. [1–2]

Spinal anesthesia causes blockage of nerve roots as they pass through the subarachnoid space, which extends from the foramen magnum to the second sacral vertebra in adults and the third sacral vertebra in children. It is widely used to relieve pain during labor and delivery or during a cesarean section. [3–4]

Shivering after surgery is a common complication of taking It is believed that shivering increases oxygen consumption, and increases It reduces the risk of hypoxia in the blood, stimulates lactic acidosis, and It contains catecholamines, and may increase post-surgical complications, especially in Patients at risk. Moreover, trembling is one of the main causes of discomfort in Patients after surgery. [5–6]

Research importance:

Tremor is an involuntary, spontaneous, and repetitive contraction of skeletal muscles that increases patients' discomfort, hypoxia, and increases the chance of wound infection, increased surgical bleeding, and cardiovascular complications. The aim of this study was to determine the magnitude of intraoperative tremor after cesarean section and the factors associated with it.

Study design:

A cross-sectional descriptive study to determine the extent of shivering during the surgical procedure after cesarean section and the factors associated with it at Al-Zahrawi Hospital in the period extending between 8/1/2023 and 12/1/2023.

Patients:

The study included 80 patients who were admitted to Al-Zahrawi Hospital for a caesarean section.

Methods:

After approval by the Institutional Ethical Committee of Al-Zahrawi Hospital, Faculty of Medicine at the Syrian Private University, informed consent was taken from all patients. All patients who underwent cesarean section under spinal anesthesia using consecutive sampling technique were included. However, uncooperative patients were excluded. Those with cognitive impairment, psychiatric illnesses, patient refusal, patients who underwent epidural anesthesia, spinal epidural anesthesia, psychiatric disorders, and hypothyroidism or hyperthyroidism. All patients were treated with antiemetics [4 mg dexamethasone]and 10 mg metaclopramide. 30 minutes before surgery, to prevent nausea and vomiting, spinal anesthesia was performed for some patients between the third and fourth lumbar vertebrae using Markaine 0.5% [2.5 ml], and general anesthesia was also performed for some patients with propofol, and the patients’ axillary temperature, pulse rate, and blood pressure were monitored and recorded. Every 5 minutes during the surgical procedure, the severity of shivering was also assessed using the shivering score. Information was obtained such as the patient's age, weight, and height, and information was taken about pressure, fluid volume, type of intravenous fluids, state of consciousness according to the American Society of Anesthesiologists [ASA], and duration of anesthesia. And surgery. To ensure the quality of the data, an initial data collection test was conducted on 5% of the patients from the calculated sample size, but they were not included in the main study. The collected data was examined for completeness, accuracy, and clarity. The data was collected by the research team after they received directions from a physician. The anesthesiologist supervising this research.

Statistical analysis:

The data was completed from the forms into an Excel file, simple statistics were conducted, the results were summarized and explained with tables and graphs, and the descriptive statistics were reviewed based on percentages and graphical shapes in addition to measures of central tendency [arithmetic mean and standard deviation]. To test the statistical relationships between the basic characteristics, we used methods The following statistics:

Pearson's chi-square test to compare categorical variables with a normal distribution. The relationship between the dependent and independent variables was assessed using binary and multiple logistic regressions. The 95% confidence interval and the adjusted odds ratio were calculated, and the p-value to determine the associated factors and to determine the strength of the association was considered the predictive value. Less than 0.05 [p.value < 0.05]is a statistically significant value in this analysis.

Ethical considerations:

Ethical approval was obtained from the Institutional Review Board [IRB]Faculty of Medicine, Syrian Private University and director of Damascus Hospital.

80 participants were included in this study who met the criteria, and the study was conducted on all participants with a response rate of 100%. The average age of the patients was 29.2 years with a standard deviation of 7.33 years and also the average height of the patients was 1.5 cm with a standard deviation of 0.1. In this study 49 ( 61.3% of the patients were in the age group of 18–30 years, while 31 (38.8%) of the patients were in the age group of 31–43 years, and the ages of the patients ranged between 18 years and 43 years. 60 (75%) of the patients were overweight. Normal (BMI 18.5–24.9), 20 (25%) of the patients were overweight (BMI 25–29.9), all patients had a condition (ASA I, II). In this study, the average blood pressure was Systolic blood pressure was (120), with a standard deviation of (7.2), while the average diastolic blood pressure was (82), with a standard deviation of (6.1), and the average duration of surgery was (84.9), with a standard deviation of (5.9), and the average amount of fluid leaked was (6.05), with a deviation Standard (1), the average duration of surgery (66.9), with a standard deviation (13.9), and the average temperature of patients (36.66), with a standard deviation (0.88). In this study, the most common reason for performing a caesarean section was the presence of previous caesarean sections (46.3%) ), while the second most common reason for performing a caesarean section was defective delivery (28%), and the third most common reason for cephalopelvic disproportion (11.3%), and this statistic was limited to a certain number of reasons only.

In this study, the percentage of patients using general anesthesia was (37.5%), and the percentage of using spinal anesthesia was (62.5%). Ringer's lactate fluid was used by (11.3%) of patients, and saline serum was used by (88.8%) of patients. The anesthetic drug propofol was used in general anesthesia in (35%), i.e. (93.4%), of general anesthesia operations, while thiopental was used in (2.5%), i.e. 6.6% of general anesthesia operations, and the two brands were used in (62.5%). That is (100%) of spinal anesthesia operations.

Looking at the results of this statistic, we found that the incidence of shivering during the surgical procedure after a cesarean section under general or spinal anesthesia is (38.8%), with a confidence interval of 95%, and an error rate of 5%, in Al-Zahrawi Hospital, from 1/8/2023 to 1 /12/2023.

Results of bivariate and multivariable binary logistic regression analysis: Factors associated with intraoperative shivering after cesarean section under general or spinal anesthesia, at Al Zahrawi Hospital, from 8/1/2023 to 12/1/2023.

In this study, the type of anesthesia used, patient age, body mass index, patient blood pressure, body temperature, and surgical period were significantly associated with shivering in multivariable logistic regression at a significance level of less than 0.05.

In this study, general anesthesia was significantly associated with the development of tremor. Patients who underwent general anesthesia were 5 times more likely to experience tremor compared to patients who received spinal anesthesia, with Adgusted OR = 4.9 and the significance level is less than 0.0001, at a confidence interval = 95%.

In addition, there was a significant correlation between the age of patients and the outcome variable (incidence of tremor), as our results showed that patients aged 31–40 years were 5 times more likely to suffer from tremor than patients aged 18–30 years, as Adgusted OR = 5.1 and the significance level is less than 0.0001. At confidence interval = 95%.

We also found, in this cross-sectional study, that there is an important association between BMI and the outcome variable (incidence of tremors), as the results of the statistical analysis showed that patients with a normal BMI (18.5% − 24.9) were 7 times more likely to have tremors than those with a normal BMI (18.5% − 24.9). Patients with BMI range 25–29.9, where Adgusted OR = 6.8, significance level less than 0.0001. At confidence interval = 95%.

In addition, there was a significant association between low blood pressure and the outcome variable (incidence of tremor), so our results showed that patients with differential hypotension were 3 times more likely to have tremor than patients with normal blood pressure. OR = 3.2, and the significance level is less than 0.0001. At confidence interval = 95%.

We also found in this study that hypothermia is significantly associated with the development of the outcome variable (the incidence of shivering), as patients suffering from hypothermia were 4 times more likely to develop shivering compared to patients who did not suffer from hypothermia, where Adgusted OR = 4.3, The significance level is less than 0.0001. At confidence interval = 95%.

Duration of surgery was also a factor associated with shivering in our study and long surgeries that lasted more than 60 minutes were 4 times more likely to have shivering than short surgeries that were less than 60 minutes, Adgusted OR = 4.1, significance level less than 0.0001. At confidence interval = 95%.

The prevalence and magnitude of postoperative shivering ranged from 5–65% of patients after general anesthesia and in 30% of patients undergoing spinal anesthesia, which is less than in our study, where the prevalence of shivering in patients who underwent general anesthesia ranged [31.3%], while The prevalence of shivering in patients who underwent spinal anesthesia ranged from 7.5% [66]. There are many factors associated with shivering, including the type and duration of anesthesia, the duration of surgery, the level of sensory blockade, gender, age, temperature of the patient, the operating room, and fluids leaked to the patient [67]. Shivering is one of the most common and unwanted complications after general and spinal anesthesia. There is no clear mechanism for shivering after spinal and general anesthesia, but there are several possible mechanisms for shivering during general anesthesia as a result of central and peripheral thermoregulation [67,68,69]. The main complication of shivering is increased oxygen consumption. It results in increased metabolic demand, which generally translates into increased oxygenation with increased minute ventilation. The metabolic demands themselves increase the capacity for peripheral oxygen delivery, lead to anaerobic metabolism, and end in cardiopathy. They also increase cardiac output, pulse rate, and intraocular pressure and interfere with monitoring of oxygen saturation, electrocardiogram, and blood pressure. [7–8–9–10–11–12].

In this study, the incidence of shivering during the surgical procedure after a caesarean section under general anesthesia was [31.3%], and the incidence of shivering during the surgical procedure after a caesarean section under spinal anesthesia was [7.5%]. This result was contrary to other studies conducted in different countries on Although they use warming the air used in mechanical ventilation and warming intravenous fluids before injecting them into patients [76,77,78]. In addition, the prevalence of shivering ranged between 36% and 85% of patients undergoing a caesarean section under spinal anesthesia, which was the preferred anesthesia method among doctors, while the prevalence of shivering ranged between 40% and 75% of patients undergoing a caesarean section under general anesthesia.. [13–14–15].

The incidence of shivering after spinal anesthesia in this study is equal to the rate in a study conducted in sub-Saharan Ethiopia [8.1%], and this may be due to the use of an air warming device and due to heating of fluids. The reason may be unknown, as is the matter related to general anesthesia. [17]

Some studies have shown that being male has a higher risk of shivering [26–27–28–29]. A female's core body temperature may be slightly higher than that of a man, but in other studies there was no significant difference between the sexes for shivering [18–19], however we could not see a difference in our study due to the same gender which were all female.

In this study, there was a significant correlation between the age of patients and the outcome variable [incidence of tremor], as our results showed that patients aged 31–40 years were 5 times more likely to suffer from tremor than patients aged 18–30 years, but Few studies support this finding [88, 89], but some studies have shown that being a young adult has a higher prevalence of shivering than an older adult [21–22–23–24–25], which may be because thermoregulatory responses to cold and heat Weak in older patients.

Many studies have been done to prevent hypothermia and reduce the incidence of shivering after anesthesia. Non-pharmacological methods are used to reduce the incidence of shivering such as radiant heat warmers, operating room warmers, blankets, and the use of intravenous [IV]fluids at body temperature. There are also pharmacological methods Various medications for tremor including intravenous fentanyl, tramadol, pethidine, magnesium sulfate, and ketamine [31–32–33–34–35–36–37]

There are four ways in which the human body loses heat: conduction, convection, radiation, and evaporation. Hypothermia is usually caused by prolonged exposure to cold temperatures, and shivering is a protective response to heat production through muscle activity. However, environments can also lead to hypothermia, depending on a person's age, body mass, body fat, overall health, and the length of time they are exposed to cold temperatures. In our study, hypothermia was the main factor for shivering and was supported by different studies [38–39–40–41–42–43–44–45].

In addition to hypothermia, hypotension was also the main factor for the development of shivering in the perioperative period and is supported by studies conducted in sub-Saharan countries [46]. The hypotension that occurred after spinal anesthesia may be due to a vasodilatory effect and increased heat loss from the surface Skin. However, there was no difference between systolic and diastolic blood pressure for tremor incidence in another study [47].

Another major factor associated in our study was the duration of surgery to the development of tremor after spinal anesthesia. It was similar to different studies [48].

During the long duration of anesthesia and surgery, the patient may be exposed to the surrounding environment and develop hypothermia due to heat loss and end up shivering.

Also, the BMI had a major role in the occurrence of shivering, as the higher the BMI, the lower the incidence of shivering, perhaps due to the ability of adipose tissue to warm the body and prevent the waste of heat, thus preventing the occurrence of shivering. [49–50].

Another major factor associated in our study was the duration of surgery to the development of tremor after spinal anesthesia. It was similar to different studies [51], it may be that during the long duration of anesthesia and surgery, the patient is exposed to the surrounding environment and develops hypothermia due to heat loss and ends up shivering.

Ethics approval and consent to participate:

The Research Ethics Committee in the Syrian Private University and the ethical committees in the concerned Syrian private university approved the study protocol. Verbal informed consent was obtained from every participant before participation. All procedures performed in studies involving human participants were by the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Consent for publication:

Not applicable.

Availability of data and materials:

All data related to this paper’s conclusion are available and stored by the authors. All data are available from the corresponding author on a reasonable request.

Conflict of interest:

The authors declare that they have no conflict of interest

Funding:

This research received no specific grant from SPU or any other funding agency in the public, commercial or non-profit sectors.

Authors’ contributions:

A.A conceptualized the study, L.A wrote the study protocol, performed the statistical analysis, participated in data collection, and did the literature search. L.A participated in the literature search, interpret the results, wrote the main manuscript, N.R. revised the draft. All authors read and approved the final draft.

Acknowledgments:

We are thankful to the management of the Syrian Private University and for their support in the field of medical training and research. And the medical staff at Al-Zahrawi Hospital We would also like to thank Dr. Houssam Bardan for his help and supervision in the paper.

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The authors declare potential competing interests as follows: no

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A study of the incidence of shivering after cesarean section surgery, a comparative study between general and spinal anesthesia

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Introduction

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