|Year : 2016 | Volume
| Issue : 3 | Page : 349-352
Prophylactic dexamethasone or pethidine for the prevention of postoperative shivering during transurethral resection of the prostate under spinal anesthesia
Abd El Azeem A El Bakry MD , Ezzeldin S Ibrahim
Department of Anesthesia, Faculty of Medicine, El Menoufia University, Shibin El Kom, Egypt
|Date of Submission||29-Aug-2015|
|Date of Acceptance||06-Apr-2016|
|Date of Web Publication||31-Aug-2016|
Abd El Azeem A El Bakry
Anesthesia Department, Faculty of Medicine, El Menoufia University, El Menoufia Governorate, Shibin El Kom, Yassine Abd El Ghafar Street, Egypt
Source of Support: None, Conflict of Interest: None
Shivering is a common complication in elderly patients undergoing urologic operations under spinal anesthesia. The present study compares the effect of prophylactic dexamethasone and pethidine on shivering during transurethral resection of the prostate (TURP) under spinal anesthesia.
Patients and methods
This random prospective double-blinded controlled study was conducted on 90 patients scheduled for TURP operations under spinal anesthesia. Patients were allocated into three groups: in the C group, patients were administered intravenous 10 ml normal saline before spinal anesthesia. In the P group, patients were administered 25 mg pethidine in 10 ml normal saline. In the D group, patients were administered 0.1 mg/kg dexamethasone in 10 ml normal saline. Core body temperature, mean arterial blood pressure, respiratory rate, oxygen saturation, incidence and severity of shivering, nausea, vomiting, and pruritus were recorded.
The incidence and severity of shivering were low in the pethidine and dexamethasone groups compared with the control group (P < 0.05), with no significant difference between the pethidine and dexamethasone groups (P > 0.05).
Prophylactic dexamethasone is as effective as pethidine in reducing the incidence and severity of shivering in TURP patients under spinal anesthesia.
Keywords: cystoscopy, dexamethasone, pethidine, shivering, spinal anesthesia
|How to cite this article:|
El Bakry AA, Ibrahim ES. Prophylactic dexamethasone or pethidine for the prevention of postoperative shivering during transurethral resection of the prostate under spinal anesthesia. Ain-Shams J Anaesthesiol 2016;9:349-52
|How to cite this URL:|
El Bakry AA, Ibrahim ES. Prophylactic dexamethasone or pethidine for the prevention of postoperative shivering during transurethral resection of the prostate under spinal anesthesia. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2021 Apr 14];9:349-52. Available from: http://www.asja.eg.net/text.asp?2016/9/3/349/189575
The study was primarily carried out in El Menoufia University Hospital.
| Introduction|| |
Transurethral resection of the prostate (TURP) is commonly performed under spinal anesthesia and produces sympathetic block, leading to peripheral vasodilatation, which, in addition to the use of cold irrigating fluids, predisposes the occurrence of shivering .
Most patients undergoing TURP are elderly patients with weak autonomic protective responses, and shivering has many undesirable effects such as increased oxygen consumption, increased carbon dioxide production, and patient discomfort . These side effects increase the load on the cardiorespiratory system, especially in elderly patients with low cardiorespiratory reserve .
Mepredine, commonly known as pethidine, is considered the main effective drug against shivering, but its side effects such as nausea, vomiting, and respiratory depression, which are dose dependent, are limitations to its use and prolong hospital stay .
The present study was conducted to study the effect of a prophylactic dose of dexamethasone on shivering compared with prophylactic low-dose pethidine in patients undergoing TURP under spinal anesthesia.
| Patients and methods|| |
After approval of the ethics committee and after obtaining informed written consent, 90 male patients of American Society of Anesthesiologists (ASA) I and II physical status between 60 and 80 years of age scheduled for TURP using cystoscopy were included in the study, which was conducted in El Menoufia University Hospitals from November 2014 to August 2015. Exclusion criteria were as follows: a history of sensitivity to the drugs of the study; having neuromuscular disease or neurologic disturbances; taking α2-blocking drugs; having fever or hypothermia; a history of peptic ulcer; having uncontrolled diabetes mellitus; and contraindications to spinal anesthesia. In the present prospective double-blinded controlled study patients were randomly allocated using computerized systems using the software from the internet link site (http://www.graphpad.com/quickcalcs/index.cfm) into three groups, 30 patients each group. In the control group (the C group), patients were administered intravenous 10 ml normal saline. In the pethidine group (the P group), patients were administered intravenous 25 mg pethidine (pethidine 50 mg/ml; Misr company for pharmaceuticals, Abo Zaabal, Qalubia, Egypt) completed to 10 ml volume with normal saline. In the dexamethasone group (the D group), the patients were administered intravenous 0.1 mg/kg dexamethasone (dexamethasone 4 mg/ml; Egyptian. Int. Pharmaceutical industries Co. 10 th of Ramadan city, Egypt) completed to 10 ml volume with normal saline. All patients were subjected to spinal anesthesia and all medications were administered to the patients just before induction of spinal anesthesia. Spinal anesthesia was performed under complete aseptic conditions in the sitting position at L4–L5 or L3–L4 interspace using 3 ml of 0.5% hyperbaric bupivacaine (Marcaine Spinal Heavy, Astrazeneca, Sweden); the block was achieved to T9–T10 level. The operating room temperature was adjusted to 22–24°C and all intravenous and irrigation fluids were adjusted to this temperature. All patients were connected to a monitor (Nihon Khoden, Tokyo, Japan) for heart rate, blood pressure, oxygen saturation, and respiratory rate and recorded at the following intervals:baseline, one minute after spinal anesthesia, every 10 min intraoperatively, at the end of surgery, before discharging the patient from the recovery room, and every 1 h postoperatively until recovery from spinal anesthesia. In case of hypotension, the patients were managed with intravenous loading with Ringer's lactate and boluses of 10 mg ephedrine. Core body temperature was recorded using tympanic probe (Nihon Khoden, Tokyo, Japan). The body temperature was recorded at the following intervals: baseline, one minute after spinal anesthesia, every 10 min intraoperatively, at the end of surgery, before discharging the patient from the recovery room, and every 1 h postoperatively until recovery from spinal anesthesia. Intensity of shivering was graded according the following scale in [Table 1].
Intense shivering (grades 3 and 4) was treated with 25 mg of intravenous pethidine. Hypothermia was also recorded and managed by maintaining body temperature with warm intravenous fluids and warming blanket. Other side effects were recorded, including nausea, vomiting, pruritus, and respiratory depression.
| Power analysis|| |
Sample size calculation was carried out using Graphpad instat program version 3 (GraphPad Software Inc. California, USA). From previous studies, both drugs expected to reduce 30% of shivering rate. At an a angle 5% and 90% power, the sample size was 22, and hence a sample size of 30 was chosen to ensure accuracy.
| Statistical analysis|| |
Statistical analysis was carried out using SPSS 19 (SPSS Inc, Chicago, USA). Patient characteristics, duration of surgery, core body temperature, and mean arterial blood pressure (MABP) were expressed as mean ± SD. Intensity of shivering and other incidence parameters were expressed as number and percentage. Comparison among groups was made using the analysis of variance test with Tukey's test as post-hoc test if there was statistical significance. Paired comparisons were analyzed using the paired t-test. For the incidence and severity of shivering and the incidence of side effects the χ2-test was used. A P-value less than 0.05 was considered statistically significant.
| Results|| |
As regards the patient's age, weight, and duration of surgery, there was no statistically significant difference among all groups (P > 0.05) [Table 2].
As regards heart rate, oxygen saturation, and respiratory rate, there was no statistically significant change among groups at all times of measurement (P > 0.05). As shown in [Figure 1], in all groups there was a statistically significant reduction in the MABP during the first 20 min after spinal anesthesia compared with the baseline value (P < 0.05). At other times of measurement until recovery from spinal anesthesia, the MABP changes were not significant compared with the baseline value in all groups (P > 0.05). The MABP changes were not significant on comparing the three groups at all times of measurement (P > 0.05). The number of patients with hypotension who needed treatment was 10 (33.33%) in the control group, nine (30%) in the P group, and 11 (36.6%) in the D group, with no statistical significance (P > 0.05). As shown in [Figure 2], as regards the baseline values of the core body temperature in the three groups, there was no significant difference among groups (P > 0.05). In the intraoperative period, there was a significant reduction in the core body temperature compared with the baseline values during the first 20 min after anesthesia (P < 0.05). In the three groups, the core body temperature changes were nonsignificant at all times of measurement compared with each other (P > 0.05). The incidence of shivering was significantly high (P < 0.05) in the C group (15 patients, 50%) compared with the D group (six patients, 20%) and the P group (seven patients, 23%), with no statistically significant difference between the D and P groups (P > 0.05). The intensity of shivering was significantly high (P < 0.05) in the control group compared with other groups, with no statistically significant difference between the P and D groups (P > 0.05) [Table 3]. The number of patients with nausea was three (10%) in the C group, five (16.6%) in the P group, and three (10%) in the D group, with no statistical significance (P > 0.05). The number of patients with vomiting was two (6.6%) in the C group, three (10%) in the P group, and two (6.6%) in the D group, with no statistical significance among groups (P > 0.05). No reported case of respiratory depression, pruritus, or bradycardia needed treatment.
| Discussion|| |
The present study was conducted on 90 patients who underwent TURP under spinal anesthesia, to compare the effects of prophylactic low-dose pethidine (25 mg) and 0.1 mg/kg of dexamethasone on shivering. Yared et al. , in a study conducted on patients scheduled for cardiopulmonary bypass under general anesthesia, concluded that dexamethasone (0.3–0.6 mg/kg) was effective in preventing postoperative shivering.
These results are in agreement with those of the present study despite the small dose of dexamethasone (0.1 mg/kg) used in the present study, which was considered an advantage to be effective with minimal side effects. The large dose of dexamethasone used in the study by Yared and colleagues was beneficial, as many factors other than hypothermia affects thermoregulatory center, such as the release of cytokines and prostaglandins.
In the present study, both pethidine and dexamethasone did not affect the drop of the core body temperature in the three groups, as there was no statistically significant difference among groups. They only decreased the incidence and severity of shivering. The mechanism of action of dexamethasone may be attributed to its central inhibitory effect on the thermoregulatory center and inhibition of release of cytokines and inflammatory mediators, which affect the thermoregulatory center . Pethidine mechanism of action is still not clear, but it may produce its action through inhibition of the thermoregulatory center or through opioid receptor mechanism .
A limitation to the present study was that spinal anesthesia produced vasodilatation in the lower half of the body, which may affect the surface to core body temperature gradient and may result in inaccuracy when measuring the surface body temperature, and hence core body temperature was used only to relate to the actual temperature change that occurred.
In the present study, there was no reported case of pruritus or respiratory depression, and the incidence of nausea and vomiting was comparable in the three groups. These observations may be due to the use of low-dose pethidine and not affected or decreased by the use of dexamethasone, as previous research studies revealed that dexamethasone had no effect on the postoperative nausea, vomiting, and pruritus induced by opioids ,.
Despite the effect of dexamethasone on inhibition of release of vasodilator inflammatory mediators, which may affect the MABP , in the present study the drop in the MABP during the first 20 min that occurred in all groups was not statistically significant and was attributed to the effect of spinal anesthesia.
Studies on prophylactic dexamethasone for the prevention of postoperative shivering showed results similar to the present study ,. However, as regards the use of prophylactic pethidine, some studies prove that it was effective, which is in agreement with the present study ,, whereas other studies proved that it was not effective ,.
| Conclusion|| |
From the results of the present study we conclude that prophylactic dexamethasone is as effective as pethidine in reducing the incidence and severity of shivering in TURP patients under spinal anesthesia.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]