Review Article

Shivering and Neuraxial Anesthesia

Larry J. Crowley, M.B., M.R.C.P.I., F.C.A.R.C.S.I., and
Donal J. Buggy, M.D., F.R.C.P.I., F.C.A.R.C.S.I., F.R.C.A.
Shivering, which usually occurs as a thermoregulatory response to cold, may also occur following general or
neuraxial anesthesia. Some of the causative factors of this type of shivering may be common to both, but some
are particular to neuraxial anesthesia. Although shivering may have beneficial thermoregulatory effects, it
places the body under increased physiological stress. In a broad sample of 21 studies, the median incidence of
shivering related to neuraxial anesthesia in the control groups was 55%. Both pharmacological and nonpharmacological mechanisms have been found to be effective in reducing this shivering. This review aims to
elucidate the mechanisms of the shivering that occurs during neuraxial anesthesia, and to examine strategies for
prevention and treatment of this shivering. Reg Anesth Pain Med 2008;33:241-252.
Key Words:

Epidural anesthesia, Spinal anesthesia, Shivering, Anesthesia side effects.

hivering may be defined as an involuntary, repetitive activity in skeletal muscles. Shivering

usually occurs as a thermoregulatory response to
cold, although nonthermoregulatory shivering may
also occur. Core temperature in humans varies with
circadian rhythm (and with menstrual cycle in females), but is normally maintained within the narrow range of 36.5C to 37.0C. Shivering may occur
following general or neuraxial anesthesia, and undoubtedly some of the causative factors are common to both. However, as this review will demonstrate, some factors are particular to neuraxial
anesthesia. This review aims to elucidate the mechanisms of the shivering that occurs during neuraxial
anesthesia, and to examine strategies for prevention and treatment of this shivering.

Search Method
An unlimited search of the PubMed database (extending from the 1950s) was conducted up to the
end of October 2007 using the key phrases shivering and epidural anesthesia and shivering and
From the Department of Anesthesia, Intensive Care & Pain
Medicine, Mater Misericordiae University Hospital, Dublin, Republic of Ireland.
Accepted for publication November 20, 2007.
Reprint requests: Larry J. Crowley, M.B., M.R.C.P.I.,
F.C.A.R.C.S.I., Department of Anesthesia, Intensive Care & Pain
Medicine, Cork University Hospital, Cork, Republic of Ireland.
E-mail: larryjcrowley@gmail.com
2008 by the American Society of Regional Anesthesia and
Pain Medicine.
1098-7339/08/3303-0001$34.00/0
doi:10.1016/j.rapm.2007.11.006

spinal anesthesia. All retrieved articles were analyzed for information that was used to construct this
review. The reference lists of retrieved articles and
relevant review articles were also examined.

Incidence in Neuraxial Anesthesia

The median incidence of shivering related to
neuraxial anesthesia in the control groups of a
broad sample of 21 studies is 55% (interquartile
range of 40%-64%).1-21 Within these studies there
is a heterogeneity of study populations, definition
of shivering, study design, and research questions.

Adverse Effects of Shivering

Although shivering may have beneficial thermoregulatory effects, it places the body under increased physiological stress, which may be deleterious.22 Shivering may double oxygen consumption
and carbon dioxide production, although increase
of the latter is typically much smaller.23,24 Plasma
catecholamines and cardiac output increase in response to this physiological stress.25 Shivering
movements during neuraxial anesthesia may interfere with monitoring of blood pressure, electrocardiogram, and pulse oximetry,26,27 as well as reducing patient comfort and satisfaction.28

Grading of Shivering
Grading and definition of shivering are important
to allow meaningful comparisons of interventions
in this area. An attempt has been made to grade

Regional Anesthesia and Pain Medicine, Vol 33, No 3 (MayJune), 2008: pp 241252

241

242

Regional Anesthesia and Pain Medicine Vol. 33 No. 3 MayJune 2008

shivering on the following scale: 0, no shivering; 1,

piloerection or peripheral vasoconstriction but no
visible shivering; 2, muscular activity in only one
muscle group; 3, muscular activity in more than
one muscle group but not generalized shivering;
and 4, shivering involving the whole body.29 An
alternative, more user-friendly, scale specific for
neuraxial anesthesia would be: 0, no shivering; 1,
shivering not interfering with monitoring or causing patient distress; and 2, shivering interfering
with patient monitoring or causing patient distress.

Mechanisms
Neurophysiology
Similar to other physiological systems, the human thermoregulatory system is often divided into
3 components: thermosensors and afferent neural
pathways, a center for integration of this input, and
effector pathways. Although incompletely understood, many of the neural pathways involved in
thermoregulation have been elucidated and summarized elsewhere.30 A simplified schematic representation of the shivering pathway is illustrated in
Figure 1. The lateral spinothalamic tract projects to
the hypothalamic thermoregulatory centers and to
nuclei within the reticular formation in the pons. The
nucleus raphe magnus facilitates transmission of thermal information to the hypothalamus and has an
inhibitory role in shivering. The locus subcoeruleus
appears to have a predominantly excitatory role in
shivering. The preoptic area of the anterior hypothalamus appears to be the central integrator of input. The
efferent shivering pathway starts at an area between
the anterior and posterior hypothalamus and makes

Fig 1. Schematic diagram of the shivering pathway.

multiple connections within the reticular formation

before it ends at the motor neurons.
Thermoregulation
Undoubtedly, shivering occurs primarily in response to core hypothermia. The normal response
to hypothermia involves thermoregulatory vasoconstriction to decrease cutaneous heat loss, and maintain heat within the core. Maximal vasoconstriction
usually occurs before thermoregulatory shivering occurs. When the core temperature decreases to a certain point, known as the shivering threshold, thermoregulatory shivering then occurs. The threshold
temperature at which shivering occurs may be
lower in males relative to females, and may also
decrease with age.31,32 A decrease in core temperature (measured at the tympanic membrane) of
0.5C is sufficient to induce shivering in nonpregnant volunteers undergoing epidural anesthesia.33
The shivering that occurs during epidural anesthesia is accompanied by central hypothermia and
peripheral vasoconstriction above the level of the
block, and is thus primarily normal thermoregulatory shivering.33 The normal response to warming
of the legs is a reduction of the shivering threshold.34 Hynson et al. demonstrated that core hypothermia during the first hour of epidural anesthesia
does not result from heat loss to the environment in
excess of metabolic heat production, but rather
from redistribution of core body heat to the peripheral tissues.35 Matsukawa et al. demonstrated that
the magnitude of this decrease for epidural anesthesia was 0.8C 0.3C in the first hour, and a
further 0.4C 0.3C in the subsequent 2 hours, as
well as confirming that redistribution of heat from
the core to the periphery is responsible for this
decrease.36 Neuraxial block results in impairment of
autonomic thermoregulation below the level of the
block. The vasodilatation that occurs below the
level of a neuraxial block is presumably responsible
for this redistribution of heat. One might expect a
greater degree of vasodilatation (and thus decrease
in core temperature) following spinal block. Saito et
al. demonstrated that for the first 30 minutes of
anesthesia, core temperature decreased significantly faster in patients given spinal block when
compared with those given epidural block. After 30
minutes, core temperatures decreased at identical
rates during epidural and spinal anesthesia, with
the end result being lower core temperature in the
spinal group.13 Thus one might expect higher rates
of shivering with spinal block compared with epidural block, but as discussed below, this does not
appear to be the case.

Shivering and Neuraxial Anesthesia

Epidural Versus Spinal

Studies comparing the incidence of shivering for
epidural versus spinal anesthesia are lacking, although the intensity of shivering seems to be
greater during epidural anesthesia.13 Neuraxial anesthesia will block all thermal sensations, but at
typical ambient temperatures, is likely to block tonically-firing cold thermoreceptors more than warm
thermoreceptors.37 Epidural anesthesia increases
the apparent leg temperature (as distinguished from
the actual leg temperature) perceived by the body,
and this results in a decreased shivering threshold.38
Spinal anesthesia decreases the shivering threshold
in direct relation to the number of dermatomes
blocked, i.e., less shivering with increased block
height.39 To better understand the mechanisms of
shivering during neuraxial anesthesia, it is important to try to explain the observed differences between epidural and spinal anesthesia. Spinal anesthesia usually results in complete block of all
neurons below a certain level, whereas epidural
anesthesia may result in a segmental block that
often fails to block sacral dermatomes. Thus, for a
given block height, block of thermal input during
epidural anesthesia may be reduced relative to spinal anesthesia. This may result in less of a decrease
in the shivering threshold relative to spinal anesthesia, and provide a possible explanation as to why
shivering appears to be more intense following epidural block. Perhaps the simplest explanation for
the apparent difference is the greater intensity of
motor block with subarachnoid block compared
with that in epidural block, such that patients are
actually unable to shiver during subarachnoid
block. It is unclear whether epidural or spinal block
affect the shivering threshold in different ways.
Saito et al., studying 30 parturients having elective
cesarean delivery with epidural or spinal anesthesia, demonstrated a higher shivering threshold
when using epidural anesthesia.13 In contrast,
Ozaki et al., studying 7 male volunteers, failed to
show a difference in shivering thresholds for epidural versus spinal anesthesia.40 It is theoretically
possible that there are different thermoreceptors
and mechanisms within the spinal cord compared
with those within the epidural space.
Temperature of Administered Fluid
It has long been known that the spinal cord has
thermoreceptors and is involved in thermoregulation.41 Administration of cold fluids into the epidural space may result in cooling of large epidural
veins, which in turn communicate with the basal
sinuses. This might also provide an explanation for
the apparent difference in shivering intensity for

Crowley and Buggy

243

epidural and spinal anesthesia. There seems to be

some evidence that the temperature of epidural
injectate may influence shivering. Ponte et al.
found a statistically significant different incidence of
shivering when studying 40 patients having elective
cesarean delivery and epidural anesthesia. Shivering occurred in 9 of 20 who received epidural bupivacaine at 4C, compared with 2 of 20 who received epidural bupivacaine at 37C.42 Shehabi et
al. demonstrated a similar reduction in shivering for
patients receiving epidural bupivacaine warmed to
36.3C, compared with bupivacaine at room temperature (22.3C).6 In a study by Walmsley et al., 30
patients having postpartum tubal ligation received
epidural bupivacaine at 4C, with shivering occurring in 14 of 30 (47%). Eight of the 14 had marked
shivering and then received further epidural bupivacaine at 41C, whereupon shivering ceased in 4
of the 8 (50%).43 Two subsequent studies (on volunteers) failed to demonstrate that epidural injectate
temperature influences the incidence of shivering, although both studies had small sample size.33,44 It is
unknown whether or not the temperature of intrathecal injectate influences shivering. The temperature of intravenous fluids may also contribute to
shivering. Workhoven et al., studying 44 parturients having elective cesarean delivery and epidural
anesthesia, demonstrated that shivering occurred in
14 of 22 who received room temperature (20C22.2C) intravenous crystalloid. This compared
with only 3 of 22 who received warmed (30C33.9C) intravenous fluids.3
General Versus Neuraxial
Although the pathophysiological mechanisms of
shivering during general anesthesia and neuraxial
anesthesia are intertwined, there are subtle differences. For both, significant vasodilatation that results in heat loss may result in thermoregulatory
shivering. During general anesthesia, normal thermoregulatory mechanisms are impaired by incompletely understood mechanisms, and thus shivering
usually occurs only on awakening. Segmental block
of neural input during neuraxial anesthesia constitutes a unique causative mechanism and also allows
a degree of compensatory vasoconstriction and
shivering above the level of the block. General and
neuraxial anesthesia have distinct effects on the
release of stress hormones, metabolic heat production, and transmission along pain pathways; all of
which may have differing effects on thermoregulation and shivering. Electromyographic studies of shivering, using isoflurane anesthesia in volunteers (not
undergoing surgery), revealed that shivering is composed of 2 distinct patterns of muscular activity: a

244

Regional Anesthesia and Pain Medicine Vol. 33 No. 3 MayJune 2008

tonic pattern with 4 to 10 cycles per minute, resembling normal thermoregulatory shivering, and a
clonic pattern of 5 to 7 cycles per second, consistent with uninhibited spinal reflexes.45 It was also
demonstrated that deep tendon reflexes are significantly exaggerated by central hypothermia. Analysis of electromyographic patterns of shivering, following epidural anesthesia in nonpregnant
volunteers, revealed the tonic pattern of normal
thermoregulatory shivering but failed to demonstrate any clonic tremor pattern.35
Pregnancy
Many of the studies on shivering feature parturients having labor epidural analgesia or cesarean
delivery with epidural or spinal anesthesia. Although there are no studies comparing shivering
in this group versus males or nonpregnant females, the median incidence in published studies
for this group is 52.5% (interquartile range of
36%-71%).2,4,6-8,10,11,13,14,17,18,21 This occurs despite
the increase in temperature that normally occurs
during labor,46 and the increase in temperature associated with epidural analgesia.47,48 A review of
the hyperthermia related to labor epidural analgesia
(and the associated shivering) offered many theories as to its causation, but it remains something of
an anomaly.49 Indeed it is possible that shivering
during labor (with or without neuraxial anesthesia)
may be a phenomenon different than thermoregulatory shivering in a non-pregnant population.
Shivering that occurs in the context of hyperpyrexia will lead to a further increase in temperature.
It is known that the shivering threshold varies with
gender, with females shivering at a higher threshold temperature relative to males.31 The influence
of hormonal changes during pregnancy on shivering is unknown. Thermoregulatory shivering may
occur in up to 14.5% of laboring women even
before epidural block.2 Shivering during epidural
block is more common among parturients who
shiver prior to institution of epidural block, and in
those who receive nitrous oxide.2 It has long been
hypothesized that the shivering that occurs in the
peripartum period may be an immunological result
of fetomaternal transfusion.50,51 Nonthermoregulatory shivering also occurs in parturients with labor
epidural analgesia.52
Opioids
Opioid peptides have varying effects on body
temperature.53 Intrathecal and epidural opioids
commonly cause a small decrease in core temperature.54-56 One might expect increased shivering to
occur as a result. However as discussed below, ad-

ministration of opioids plays a significant role in the

prevention and treatment of shivering.

Prevention and Treatment

Nonpharmacological Measures
The redistribution of heat from the core to peripheral tissues, which occurs during neuraxial anesthesia, may cause hypothermia, which in turn
may result in thermoregulatory shivering. By
warming the peripheries, it should be possible to
reduce this temperature gradient, and thus reduce
shivering. Glosten et al. prewarmed volunteers for 2
hours, using a forced-air warming mattress set to
38C, before performing epidural block. They demonstrated significantly higher skin temperatures,
smaller decrease in core temperature, and reduced
incidence of shivering, when compared with unwarmed volunteers.57 Horn et al. prewarmed parturients, who were having elective cesarean delivery with epidural anesthesia, for 15 minutes using a
forced-air warming cover set to 43C, and demonstrated significantly higher core temperatures, and
less shivering in the prewarmed group. Interestingly, they also demonstrated that babies of prewarmed mothers had significantly higher rectal
temperatures (37.1C 0.5C vs. 36.2C 0.6C),
and umbilical vein pH (7.32 0.07 vs. 7.24
0.07).14 In contrast, application of an intraoperative
forced-air warmer to the lower body of parturients
having elective cesarean delivery and spinal anesthesia did not prevent intraoperative hypothermia
or shivering.21 In this study, shivering was not the
primary outcome, and thus the sample size may
have been inadequate to demonstrate a difference.
The application of a forced-air warmer to those with
established shivering following general anesthesia
was also not beneficial.58 Using an aluminum space
blanket, in parturients having labor epidural analgesia, Buggy and Gardiner reduced the intensity of
shivering, but failed to increase skin temperature,
and thus failed to reduce the incidence of shivering.10 Wrapping of the legs in elastic bandages did
not decrease the incidence of shivering in parturients having cesarean delivery with epidural anesthesia.17
Pharmacological Measures
Much work has been done to examine the effects
of multiple pharmacological agents on thermoregulation and shivering. Many of the studied agents
have analgesic and sedative properties, and probably influence thermoregulation via effects on neurotransmission and neuronal receptors. Agents
usually mediate effects via one or more of the

Table 1. Pharmacological Agents Used in the Prevention and Treatment of Neuraxial Anesthesia Shivering
Agent
(Pharmacology)

Dose

Route

Study
Population

Number of
Subjects

Time of
Administration

32 Treatment;
48 control

Epidural initiation

Significantly
decreased

None

Labor epidural
analgesia

32 Treatment;
29 control

Established
shivering

Significantly
decreased

None

Juneja60

Male,
urological
surgery,
spinal
anesthesia
Knee
arthroscopy,
spinal
anesthesia
Labor epidural
analgesia
and
epidural for
cesarean
delivery
Extracorporeal
shock
lithotripsy,
epidural
anesthesia
Labor epidural
analgesia

48 Treatment;
52 control

90 Minutes
before spinal

Significantly
decreased

Not mentioned

Mao61

50 Treatment;
50 control

Spinal initiation

Significantly
decreased

None

Sia12

20 Treatment;
20 control

Established
shivering

Decreased;
significance
unknown

Hypotension with
90 mcg

20 Treatment;
20 control

20 Minutes
before
epidural

Significantly
decreased

Drowsiness

Yang9

20 Treatment;
20 control

Established
shivering post
delivery

Significantly
decreased

Mercadante63*

50 Treatment;
50 control

5 Minutes before
spinal

Significantly
decreased

Decreased heart
rate and blood
pressure;
increased
drowsiness
Sedation

50 Treatment;
50 control

Spinal initiation

No change

None

Jeon19

31 Treatment;
38 control

Established
working
epidural

Significantly
decreased

Increased sedation

Buprenorphine (mixed ,, and opioid agonist/antagonist)

0.3 mg
Epidural
Labor epidural
analgesia

Butorphanol ( agonist and competitive antagonist)

1 mg
Epidural
Clonidine (2 agonist)
150 mcg

Oral

Intravenous

150 mcg

Intravenous

150 mcg

Intravenous

1 mcg/kg

Intravenous

150 mcg

Intrathecal

4.5 mcg/mL
(median
dose 28
mcg/hour)

Patient-controlled
epidural
analgesia

Orthopedic
surgery,
spinal
anesthesia
Orthopedic
surgery,
spinal
anesthesia
Labor epidural
analgesia

German
language;
unknown
sample size
calculation.

75% success with

30 mcg;
crossover
design.

Report First
Author

Lehmann59

Capogna62

Jeon19

Shivering not
primary
outcome
measure.

Paech64

Crowley and Buggy

30 mcg bolus
every 5
minutes to
maximum
of 90 mcg

Notes

Intravenous

Side Effects

Shivering and Neuraxial Anesthesia

1 mcg/kg

Incidence of
Shivering

245

246

Agent
(Pharmacology)

Dose

Route

Study
Population

Number of
Subjects

Time of
Administration

Incidence of
Shivering

Side Effects

Notes

Report First
Author

Fentanyl ( agonist)
25 mcg

Epidural

50 mcg

Epidural

25 mcg

Epidural

100 mcg
bolus and
50 mcg/
hour
infusion

Epidural

20 mcg

Intrathecal

Elective
cesarean
delivery,
spinal
anesthesia

Intravenous

Urological
surgery,
spinal
anesthesia

Granisetron (5-HT3 antagonist)

3 mg

Labor epidural
analgesia
and
epidural for
cesarean
delivery
Labor epidural
analgesia
Elective
cesarean
delivery,
epidural
anesthesia
Male,
extracorporeal
shockwave
lithotripsy,
epidural
anesthesia

Established
shivering

Significantly
decreased

Nausea/vomiting

21 Treatment;
20 control
18 Treatment;
23 control

Epidural initiation

Significantly
decreased
Significantly
decreased

Not mentioned
Nonsignificant
increase in
nausea/vomiting

Papavertum,
metoclopramide
for some
patients.

Liu8

Total of 14
patients,
number in
each group
not
recorded;
no control
30 Treatment;
30 control

Epidural initiation

Shivering threshold
significantly
decreased in
fentanyl group

Not mentioned

Significantly more
intravenous
fluid in fentanyl
group.

Wheelahan66

At spinal
initiation

Statistically
significant
decrease

Not significant

40 Treatment;
40 control

At spinal
initiation

Decreased but
significance not
analyzed

Hypotension in 8,
and nausea and
vomiting in 1, of
40 subjects in
treatment group;
significance
unknown

Baseline axillary
and core
temperature
significantly
different among
groups;
metoclopramide
given to some
patients.

Sagir20

At spinal
initiation

Statistically
significant
decrease

Hypotension in 3
of 40 subjects in
ketamine group

Group of
ketamine 0.25
mg/kg with
granisetron 1.5
mg also
decreased
shivering but
significance not
analyzed.

Sagir20

Ketamine (NMDA agonist, stimulates sympathetic nervous system, and agonist, antagonist)
0.5 mg/kg
Intravenous
Urological
40 Treatment;
surgery,
40 control
spinal
anesthesia

Epidural initiation

Heterogeneous
group; some
patients
shivering before
epidural; use of
nitrous oxide.

Matthews65

20 Treatment;
21 control

Shehabi6

Techanivate67

Regional Anesthesia and Pain Medicine Vol. 33 No. 3 MayJune 2008

Table 1. (Continued)

Table 1. (Continued)
Agent
(Pharmacology)

Dose

Route

Study
Population

Number of
Subjects

Time of
Administration

Meperidine ( and 2 agonist, NMDA antagonist, inhibits 5-HT and norepinephrine uptake, antimuscarinic)
25 mg
Epidural
Labor epidural
11 Treatment;
Established
analgesia
11 control
shivering

Elective
cesarean
delivery,
epidural
anesthesia
Extracorporeal
shockwave
lithotripsy,
epidural
anesthesia

Intravenous

50 mg

Intravenous

Labor epidural
analgesia

50 mg

Intravenous

0.5 mg/kg

Intravenous

Cesarean
delivery,
epidural
anesthesia
Cesarean
delivery,
epidural
anesthesia

0.4 mg/kg

Intravenous

10 mg

Intrathecal

0.2 mg/kg

Intrathecal

Elective
orthopedic
surgery,
spinal
anesthesia
Elective
cesarean
delivery,
combined
spinalepidural
Nonemergent
cesarean
delivery,
spinal
anesthesia

Not significant

Nitrous oxide and

intramuscular
meperidine also
used.

Report First
Author

Brownridge2

47 Treatment;
47 control

Epidural initiation

Significantly
decreased

Not significant

Sutherland7

19 Treatment
(12.5 mg)
and 21
treatment
(25 mg); 20
control
20 Treatment;
20 control

15 to 30 minutes
before
epidural
initiation

Nonsignificant
trend to
decrease for
both doses

Not mentioned

Harris5

Established
shivering post
delivery

Significantly
decreased

Mercadante63*

20 Treatment;
20 control

Established
shivering

Significantly
decreased

Decreased heart
rate and
increased
drowsiness
Increased
drowsiness

15 Treatment,
other
treatment
groups of
amitriptyline
and
tramadol;
no control
25 Treatment;
25 control

Established
shivering

Significantly
decreased
compared with
amitriptyline
group

Increased
somnolence

Tsai68

At spinal
initiation

Significantly
decreased

None

Kelsaka69

30 Treatment;
30 control

At spinal
initiation

Significantly
decreased

Not significant

20 Treatment;
20 control

At spinal
initiation

Significantly
decreased

Not significant

Casey4

Intravenous
diphenhydramine
and
metoclopramide
to some
patients.

Hong70

Roy18

Crowley and Buggy

12.5 or
25 mg

Significantly
decreased

Notes

Epidural

Side Effects

Shivering and Neuraxial Anesthesia

25 mg

Incidence of
Shivering

247

248

Agent
(Pharmacology)

Dose
25 mg

Route

Lower
abdominal/
extremity
surgery,
spinal
anesthesia
Nefopam (inhibits uptake of 5-HT, norepinephrine, and dopamine)
0.15 mg/kg
Intravenous
Orthopedic
surgery,
epidural or
spinal
anesthesia
Neostigmine (anticholinesterase)
75, 150, or
Epidural
Elective
300 mcg
cesarean
delivery,
combined
spinalepidural
anesthesia
Ondansetron (5-HT3 antagonist)
8 mg
Intravenous
Elective
orthopedic
surgery,
spinal
anesthesia

Sufentanil ( agonist)
0, 25, 50, 75,
or 100 mcg

Intramuscular

Study
Population

Epidural

Number of
Subjects

Time of
Administration

Incidence of
Shivering

Side Effects

Notes

Report First
Author

30 Treatment;
30 control

15 Minutes
before spinal

Significantly
decreased

Not mentioned

Chinese
language.

Hu71

30 Treatment;
30 control

At induction of
anesthesia

Significantly
decreased

Nausea, vomiting,
sweating;
unknown
significance

Nefopam
significantly
better than
tramadol.

Bilotta16

20 Treatment
for each
dose; 20
control

Post cord
clamping

Significantly
increased with
300 mcg

Increased sedation

Unknown
incidence of
shivering at
cord clamping;
shivering not
primary
outcome.

Kaya72

25 Treatment;
25 control

At spinal
initiation

Significantly
decreased

Statistically
significant
bradycardia

Similar
effectiveness
for meperidine
0.4 mg/kg and
ondansetron 8
mg, but not an
equivalence
study.

Kelsaka69

Established
shivering

Decreased when
dose 50 mcg;
significance
unknown

Not mentioned

0.2 mcg epidural

epinephrine
given to some
patients.

Burks53

Established
shivering

Significant
decrease in time
to stop shivering
Significantly
decreased

Increased nausea/
vomiting

Japanese
language.

Chen73

Not significant

No difference in
response rate
or side effects
for both doses.

Chan74

Elective
40 Treatment;
repeat
No control
cesarean
delivery,
epidural
anesthesia
Tramadol (opioid agonist, inhibits reuptake of 5-HT, norepinephrine, and dopamine)
1 mg/kg
Intravenous
Nonparturients,
30 Treatment;
epidural
30 control
anesthesia
0.25 mg/kg
Intravenous
Elective or
13 Treatment
or 0.5 mg/kg
emergency
(0.25 mg/
cesarean
kg) and 12
delivery,
treatment
epidural
(0.5 mg/
anesthesia
kg); 11
control

Established
shivering

Regional Anesthesia and Pain Medicine Vol. 33 No. 3 MayJune 2008

Table 1. (Continued)

Tsai68

Bilotta16

Not significant

Nausea, vomiting,
sweating;
unknown
significance
Significantly
decreased
At induction of
anesthesia

Significantly
decreased
compared with
amitriptyline
group
Established
shivering

*Same study.
Same study.
Same study.
Same study.
Same study.
Same study.

Male and
female,
orthopedic
surgery,
epidural or
spinal
anesthesia
Intravenous
0.5 mg/kg

Crowley and Buggy

249

Future Directions

15 Treatment,
other
treatment
groups of
amitriptyline
and
meperidine;
no control
30 Treatment;
30 control
Intravenous
0.5 mg/kg

Cesarean
delivery,
epidural
anesthesia

Side Effects
Incidence of
Shivering
Time of
Administration
Number of
Subjects
Study
Population
Route
Dose
Agent
(Pharmacology)

Table 1. (Continued)

cholinergic, cationic, endogenous peptide, monoamine, N-methyl-D-aspartate, and serotonergic systems. Thermomodulation may occur, at peripheral
receptors, at spinal cord level, or centrally, with
some agents undoubtedly acting at multiple sites
and at multiple receptors. Agents may also demonstrate differing effects depending on the route of
administration. This complexity is reflected by the
multitude of agents whose effects on thermoregulation and shivering following general anesthesia
have been studied.30 Table 1 details studies on pharmacological agents whose effects on the shivering
specific to neuraxial anesthesia have been examined.

Notes

Report First
Author

Shivering and Neuraxial Anesthesia

The exact mechanisms underlying the observed

differences in the intensity of shivering for epidural
anesthesia and spinal anesthesia remain incompletely understood. It is also unclear whether or not
epidural and spinal block affect thermoregulation to
the same extent for a similar block height. Parturients may represent a special group, and the effects
(if any) of thermomodulation on the fetus are unknown. It is unknown whether the choice of local
anesthetic compound affects the incidence of shivering, although it has been speculated that shivering may occur more frequently when bupivacaine
is used for epidural anesthesia.75 The shivering that
occurs during general anesthesia and neuraxial anesthesia share some common pathways. Thus, it
seems likely that agents that have proven successful
in the treatment of shivering following general anesthesia, e.g., doxapram,76 ketanserin,77 physostigmine,78 and propofol,79 might also be useful in the
management of shivering during neuraxial anesthesia. Any agent that interacts with neurotransmission, in particular via the dopaminergic and serotonergic pathways, is likely to have effects on
thermoregulation, and possibly on shivering. A possible role exists for vasoconstrictor agents, which
may reduce the loss of heat from the core to peripheral tissues. Exogenous intravenously administered prostaglandin E1 has been shown to reduce
peripheral blood flow, temperature, and shivering.80 This raises questions about the potential effects of nonsteroidal anti-inflammatory drugs on
thermoregulation. The intravenous administration
of amino acid mixtures prevents the hypothermia
that occurs during spinal anesthesia, which may
have positive affects on blood loss and the incidence
of shivering.81,82 As Table 1 demonstrates, many
pharmacological agents reduce the incidence of
shivering. However, it still remains unclear which
agents may be most effective with the lowest inci-

250

Regional Anesthesia and Pain Medicine Vol. 33 No. 3 MayJune 2008

Table 2. Suggested Strategies to Prevent and Treat

Neuraxial Anesthesia Shivering
Prevention
Pre-warm patient with a forced air warmer for at least 15
minutes.14
Avoid administration of cold epidural and intravenous
fluids.3,6,42,43
Intrathecal fentanyl 20 mcg.67
Intrathecal meperidine 0.2 mg/kg or 10 mg.18,70
Intravenous ondansetron 8 mg.69
Epidural fentanyl 25 mg or 50 mg.6,8
Epidural meperidine 25 mg.7
Treatment
Intravenous meperidine 50 mg.4,63
Intravenous tramadol 0.25 mg/kg or 0.5 mg/kg or 1 mg/kg.73,74
Intravenous clonidine 30, 60, 90 or 150 mcg.62,63

dence of side effects. We require further good quality, prospective, randomized trials of adequate sample size, comparing the effects of an intervention
versus control on neuraxial shivering, where this
shivering is defined or graded, and, is the primary
outcome measure.

Conclusion
Shivering that occurs due to neuraxial anesthesia
is relatively common, and incompletely understood
(particularly in the parturient). It is likely that any
factor that causes core hypothermia may result in
thermoregulatory shivering. The shivering threshold may also be altered by many factors, e.g., the
level and type of block, and a multitude of pharmacological agents. The interplay between these
known and unknown factors determines whether
shivering occurs. As this review has demonstrated,
there are effective pharmacological and nonpharmacological mechanisms to reduce the incidence of
this shivering. Unfortunately, the heterogeneity of
study populations and design make it difficult to
apply strict evidence-based principles to the problem. Table 2 provides a suggested strategy for the
prevention and treatment of neuraxial shivering,
based on the authors opinions regarding ease of
application, the number and quality of published
studies, and the likelihood of side effects.
We must always remember that shivering is usually a normal thermoregulatory response to a potentially harmful decrease in core temperature.
Thus, if we apply mechanisms to reduce this shivering, we must ensure that we are adequately monitoring patient temperature and supplying adequate
heat to our patients.

Acknowledgments
The authors thank Drs. Joanne Douglas and
Roanne Preston for advice and guidance.

References
1. Morgan BM, Aulakh JM, Barker JP, Reginald PW,
Goroszeniuk T, Trojanowski A. Anaesthetic morbidity following caesarean section under epidural or
general anaesthesia. Lancet 1984;1:328-330.
2. Brownridge P. Shivering related to epidural blockade
with bupivacaine in labour, and the influence of
epidural pethidine. Anaesth Intensive Care 1986;14:
412-417.
3. Workhoven MN. Intravenous fluid temperature,
shivering, and the parturient. Anesth Analg 1986;65:
496-498.
4. Casey WF, Smith CE, Katz JM, OLoughlin K, Weeks
SK. Intravenous meperidine for control of shivering
during caesarean section under epidural anaesthesia.
Can J Anaesth 1988;35:128-133.
5. Harris MM, Lawson D, Cooper CM, Ellis J. Treatment
of shivering after epidural lidocaine. Reg Anesth 1989;
14:13-18.
6. Shehabi Y, Gatt S, Buckman T, Isert P. Effect of
adrenaline, fentanyl and warming of injectate on
shivering following extradural analgesia in labour.
Anaesth Intensive Care 1990;18:31-37.
7. Sutherland J, Seaton H, Lowry C. The influence of
epidural pethidine on shivering during lower segment caesarean section under epidural anaesthesia.
Anaesth Intensive Care 1991;19:228-232.
8. Liu WH, Luxton MC. The effect of prophylactic fentanyl on shivering in elective caesarean section under
epidural analgesia. Anaesthesia 1991;46:344-348.
9. Yang CH, Yu CC, Seah YS, Chan HC, Tan PP. Effect of
intravenous clonidine on prevention of postepidural
shivering. Ma Zui Xue Za Zhi 1993;31:121-126.
10. Buggy D, Gardiner J. The space blanket and shivering
during extradural analgesia in labour. Acta Anaesthesiol Scand 1995;39:551-553.
11. Plummer JL, Brownridge P. Epidural analgesia in
labour using intermittent doses determined by midwives. Int J Obstet Anesth 1998;7:88-97.
12. Sia S. I.V. clonidine prevents post-extradural shivering. Br J Anaesth 1998;81:145-146.
13. Saito T, Sessler DI, Fujita K, Ooi Y, Jeffrey R. Thermoregulatory effects of spinal and epidural anesthesia during cesarean delivery. Reg Anesth Pain Med
1998;23:418-423.
14. Horn EP, Schroeder F, Gottschalk A, Sessler DI, Hiltmeyer N, Standl T, Schulte am Esch J. Active warming during cesarean delivery. Anesth Analg 2002;94:
409-414.
15. Yu SC, Ngan Kee WD, Kwan AS. Addition of meperidine to bupivacaine for spinal anaesthesia for caesarean section. Br J Anaesth 2002;88:379-383.
16. Bilotta F, Pietropaoli P, Sanita R, Liberatori G, Rosa
G. Nefopam and tramadol for the prevention of shivering during neuraxial anesthesia. Reg Anesth Pain
Med 2002;27:380-384.
17. Sun HL, Ling QD, Sun WZ, Wu RS, Wu TJ, Wang SC,
Chien CC. Lower limb wrapping prevents hypotension, but not hypothermia or shivering, after the

Shivering and Neuraxial Anesthesia

18.

19.

20.

21.

22.
23.

24.

25.

26.
27.

28.

29.

30.

31.

32.

33.
34.

introduction of epidural anesthesia for cesarean

delivery. Anesth Analg 2004;99:241-244.
Roy JD, Girard M, Drolet P. Intrathecal meperidine
decreases shivering during cesarean delivery under
spinal anesthesia. Anesth Analg 2004;98:230-234.
Jeon YT, Jeon YS, Kim YC, Bahk JH, Do SH, Lim YJ.
Intrathecal clonidine does not reduce post-spinal
shivering. Acta Anaesthesiol Scand 2005;4:1509-1513.
Sagir O, Gulhas N, Toprak H, Yucel A, Begec Z, Ersoy
O. Control of shivering during regional anaesthesia:
Prophylactic ketamine and granisetron. Acta Anaesthesiol Scand 2007;51:44-49.
Butwick AJ, Lipman SS, Carvalho B. Intraoperative
forced air-warming during cesarean delivery under
spinal anesthesia does not prevent maternal hypothermia. Anesth Analg 2007;105:1413-1419.
Imrie MM, Hall GM. Body temperature and anaesthesia. Br J Anaesth 1990;64:346-354.
Ciofolo MJ, Clergue F, Devilliers C, Ben Ammar M,
Viars P. Changes in ventilation, oxygen uptake, and
carbon dioxide output during recovery from isoflurane anesthesia. Anesthesiology 1989;70:737-741.
Just B, Delva E, Camus Y, Lienhart A. Oxygen uptake
during recovery following naloxone. Relationship
with intraoperative heat loss. Anesthesiology 1992;76:
60-64.
Frank SM, Higgins MS, Breslow MJ, Fleisher LA,
Gorman RB, Sitzmann JV, Raff H, Beattie C. The
catecholamine, cortisol, and hemodynamic responses
to mild perioperative hypothermia. A randomized
clinical trial. Anesthesiology 1995;82:83-93.
De Courcy JG. Artefactual hypotension from shivering. Anaesthesia 1989;44:787-788.
Barker SJ, Shah NK. Effects of motion on the performance of pulse oximeters in volunteers. Anesthesiology 1996;85:774-781.
Ostheimer GW, Datha S. Observations in the postpartum recovery room after various local anaesthetic
techniques. Reg Anesth 1981;6:13-17.
Crossley AW, Mahajan RP. The intensity of postoperative shivering is unrelated to axillary temperature.
Anaesthesia 1994;49:205-207.
De Witte J, Sessler DI. Perioperative shivering: Physiology and pharmacology. Anesthesiology 2002;96:
467-484.
Lopez M, Sessler DI, Walter K, Emerick T, Ozaki M.
Rate and gender dependence of the sweating, vasoconstriction, and shivering thresholds in humans.
Anesthesiology 1994;80:780-788.
Vassilieff N, Rosencher N, Sessler DI, Conseiller C.
Shivering threshold during spinal anesthesia is reduced in elderly patients. Anesthesiology 1995;83:
1162-1166.
Sessler DI, Ponte J. Shivering during epidural anesthesia. Anesthesiology 1990;72:816-821.
Cheng C, Matsukawa T, Sessler DI, Ozaki M, Kurz A,
Merrifield B, Lin H, Olofsson P. Increasing mean skin
temperature linearly reduces the core-temperature
thresholds for vasoconstriction and shivering in humans. Anesthesiology 1995;82:1160-1168.

Crowley and Buggy

251

35. Hynson JM, Sessler DI, Glosten B, McGuire J. Thermal balance and tremor patterns during epidural anesthesia. Anesthesiology 1991;74:680-690.
36. Matsukawa T, Sessler DI, Christensen R, Ozaki M,
Schroeder M. Heat flow and distribution during epidural anesthesia. Anesthesiology 1995;83:961-967.
37. Kurz A, Sessler DI, Schroeder M, Kurz M. Thermoregulatory response thresholds during spinal anesthesia. Anesth Analg 1993;77:721-726.
38. Emerick TH, Ozaki M, Sessler DI, Walters K, Schroeder M. Epidural anesthesia increases apparent leg
temperature and decreases the shivering threshold.
Anesthesiology 1994;81:289-298.
39. Leslie K, Sessler DI. Reduction in the shivering
threshold is proportional to spinal block height. Anesthesiology 1996;84:1327-1331.
40. Ozaki M, Kurz A, Sessler DI, Lenhardt R, Schroeder
M, Moayeri A, Noyes KM, Rotheneder E. Thermoregulatory thresholds during epidural and spinal anesthesia. Anesthesiology 1994;81:282-288.
41. Cabanac M. Temperature regulation. Annu Rev Physiol
1975;37:415-439.
42. Ponte J, Collett BJ, Walmsley A. Anaesthetic temperature and shivering in epidural anaesthesia. Acta Anaesthesiol Scand 1986;30:584-587.
43. Walmsley AJ, Giesecke AH, Lipton JM. Contribution
of extradural temperature to shivering during extradural anaesthesia. Br J Anaesth 1986;58:1130-1134.
44. Ponte J, Sessler DI. Extradurals and shivering: Effects
of cold and warm extradural saline injections in volunteers. Br J Anaesth 1990;64:731-733.
45. Sessler DI, Rubinstein EH, Moayeri A. Physiologic
responses to mild perianesthetic hypothermia in humans. Anesthesiology 1991;75:594-610.
46. Marx GF, Loew DA. Tympanic temperature during
labour and parturition. Br J Anaesth 1975;47:600602.
47. Fusi L, Steer PJ, Maresh MJ, Beard RW. Maternal
pyrexia associated with the use of epidural analgesia
in labour. Lancet 1989;1:1250-1252.
48. Camann WR, Hortvet LA, Hughes N, Bader AM,
Datta S. Maternal temperature regulation during extradural analgesia for labour. Br J Anaesth 1991;67:
565-568.
49. Mercier FJ, Benhamou D. Hyperthermia related to
epidural analgesia during labor. Int J Obstet Anesth
1997;6:19-24.
50. Goodlin RC, OConnell LP, Gunthe RE. Childbirth
chills: Are they an immunological reaction? Lancet
1976;2:79-80.
51. Ravid D, Gidoni Y, Bruchim I, Shapira H, Fejgin MD.
Postpartum chills phenomenon: Is it a feto-maternal
transfusion reaction? Acta Obstet Gynecol Scand 2001;
80:149-151.
52. Panzer O, Ghazanfari N, Sessler DI, Yucel Y, Greher
M, Akca O, Donner A, Germann P, Kurz A. Shivering
and shivering-like tremor during labor with and
without epidural analgesia. Anesthesiology 1999;90:
1609-1616.
53. Burks TF. Opioids and opioid receptors in thermoregulation. In: Schonbaum E, Lomax P, eds. Thermo-

252

54.

55.

56.

57.

58.

59.

60.

61.

62.

63.

64.

65.
66.

67.

68.

Regional Anesthesia and Pain Medicine Vol. 33 No. 3 MayJune 2008

regulation: Pathology, Pharmacology and Therapy. New
York: Pergamon Press; 1991:489-508.
Sevarino FB, Johnson MD, Lema MJ, Datta S, Ostheimer GW, Naulty JS. The effect of epidural sufentanil on shivering and body temperature in the parturient. Anesth Analg 1989;68:530-533.
Kavee EH, Bernstein J, Zakowski MI, Ramanathan S.
The hypothermic action of epidural and subarachnoid morphine in parturients. Reg Anesth 1991;16:
325-328.
Hui CK, Huang CH, Lin CJ, Lau HP, Chan WH, Yeh
HM. A randomised double-blind controlled study
evaluating the hypothermic effect of 150 microg
morphine during spinal anaesthesia for caesarean
section. Anaesthesia 2006;61:29-31.
Glosten B, Hynson J, Sessler DI, McGuire J. Preanesthetic skin-surface warming reduces redistribution
hypothermia caused by epidural block. Anesth Analg
1993;77:488-493.
Alfonsi P, Nourredine KE, Adam F, Chauvin M,
Sessler DI. Effect of postoperative skin-surface warming on oxygen consumption and the shivering
threshold. Anaesthesia 2003;58:1228-1234.
Lehmann KA, Stern S, Breuker KH. Obstetrical peridural anesthesia with bupivacaine and buprenorphine.
A randomized double-blind study in comparison with
untreated controls [in German]. Anaesthesist 1992;41:
414-422.
Juneja M, Ackerman WE 3rd, Heine MF, Cases-Cristobal V, Urella RP, Rigor BM. Butorphanol for the
relief of shivering associated with extradural anesthesia in parturients. J Clin Anesth 1992;4:390-393.
Mao CC, Tsou MY, Chia YY, Chow LH, Chan KH, Lee
TY. Pre-anesthetic oral clonidine is effective to prevent post-spinal shivering. Acta Anaesthesiol Sin 1998;
36:137-142.
Capogna CT, Celleno D. IV clonidine for post-extradural shivering in parturients: A preliminary study.
Br J Anaesth 1993;71:294-295.
Mercadante S, De Michele P, Letterio G, Pignataro A,
Sapio M, Villari P. Effect of clonidine on postpartum
shivering after epidural analgesia: A randomized,
controlled, double-blind study. J Pain Symptom Manage 1994;9:294-297.
Paech M, Pavy TJ, Orlikowski CE, Evans SF. Patientcontrolled epidural analgesia in labor: The addition of
clonidine to bupivacaine-fentanyl. Reg Anesth Pain
Med 2000;25:34-40.
Matthews NC, Corser G. Epidural fentanyl for shaking in obstetrics. Anaesthesia 1988;43:783-785.
Wheelahan JM, Leslie K, Silbert BS. Epidural fentanyl reduces the shivering threshold during epidural
lidocaine anesthesia. Anesth Analg 1998;87:587-590.
Techanivate A, Rodanant O, Tachawattanawisal W,
Somsiri T. Intrathecal fentanyl for prevention of shivering in cesarean section. J Med Assoc Thai 2005;88:
1214-1221.
Tsai YC, Chu KS. A comparison of tramadol, amitriptyline, and meperidine for postepidural anesthetic

69.

70.

71.

72.

73.

74.

75.
76.

77.

78.

79.

80.

81.

82.

shivering in parturients. Anesth Analg 2001;93:

1288-1292.
Kelsaka E, Baris S, Karakaya D, Sarihasan B. Comparison of ondansetron and meperidine for prevention of shivering in patients undergoing spinal anesthesia. Reg Anesth Pain Med 2006;31:40-45.
Hong JY, Lee IH. Comparison of the effects of intrathecal morphine and pethidine on shivering after
caesarean delivery under combined-spinal epidural
anaesthesia. Anaesthesia 2005;60:1168-1172.
Hu LH, Chen JC, Lee Y, Lai KB, Wong KL, Wei TT.
Intramuscular meperidine for the prevention of shivering in spinal anesthesia [in Chinese]. Ma Zui Xue Za
Zhi 1992;30:223-228.
Kaya FN, Sahin S, Owen MD, Eisenach JC. Epidural
neostigmine produces analgesia but also sedation in
women after cesarean delivery. Anesthesiology 2004;
100:381-385.
Chen SC, Tang CS, Chen YT, Ko CJ, Yu KL, Tseng
CK, Suwa F, Ohta Y. The evaluation of the antishivering effect of tramadol during epidural anesthesia [in Japanese]. Gaoxiong Yi Xue Ke Xue Za Zhi
1994;10:632-639.
Chan AM, Ng KF, Tong EW, Jan GS. Control of
shivering under regional anesthesia in obstetric patients with tramadol. Can J Anaesth 1999;46:253-258.
Bromage PR, ed. Epidural Analgesia. Philadelphia: WB
Saunders; 1978:396.
Sarma V, Fry EN. Doxapram after general anaesthesia. Its role in stopping shivering during recovery.
Anaesthesia 1991;46:460-461.
Joris J, Banache M, Bonnet F, Sessler DI, Lamy M.
Clonidine and ketanserin both are effective treatment for postanesthetic shivering. Anesthesiology
1993;79:532-539.
Horn ED, Standl T, Sessler DI, von Knobelsdorff G,
Buchs C, Schulte am Esch J. Physostigmine prevents
postanesthetic shivering as does meperidine or
clonidine. Anesthesiology 1998;88:108-113.
Matsukawa T, Kurz A, Sessler DI, Bjorksten AR, Merrifield B, Cheng C. Propofol linearly reduces the vasoconstriction and shivering thresholds. Anesthesiology 1995;82:1169-1180.
Matsukawa T, Hanagata K, Kumazawa T, Manabe M,
Nakagomi M, Suzuki M, Nakamura T, Yamaguchi T,
Kume M, Kashimoto S. The effect of prostaglandin
E1 (PGE1) on body temperature and on postoperative shivering under high dose epidural fentanyl [in
Japanese]. Masui 1991;40:1495-1502.
Widman J, Hammarqvist F, Sellden E. Amino acid
infusion induces thermogenesis and reduces blood
loss during hip arthroplasty under spinal anesthesia.
Anesth Analg 2002;95:1757-1762.
Kasai T, Nakajima Y, Matsukawa T, Ueno H, Sunaguchi M, Mizobe T. Effect of preoperative amino acid
infusion on thermoregulatory response during spinal
anaesthesia. Br J Anaesth 2003;90:58-61.