Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942007000400012
Brazilian Journal of Anesthesiology
Review Article

Tremores intra e pós-operatório: prevenção e tratamento farmacológico

Intra - and postoperative tremors: prevention and pharmacological treatment

Viviane Ferreira Albergaria; Michelle Nacur Lorentz; Frederico Augusto Soares de Lima

http://dx.doi.org/10.1590/S0034-70942007000400012 Braz J Anesthesiol, vol.57, n4, p.431-444, 2007
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Resumo

JUSTIFICATIVA E OBJETIVOS: Os tremores podem ocorrer como um efeito adverso da intervenção cirúrgica e anestesia. A incidência de tremores pós-operatórios varia entre 6,3% e 66%. Pacientes jovens, sexo masculino, uso de agentes anestésicos halogenados e tempo prolongado de anestesia ou procedimento cirúrgico estão relacionados com tremores. Os tremores são involuntários e apresentam-se como atividade muscular oscilatória com finalidade de aumentar a produção de calor. Tremor pós-operatório é uma desagradável complicação que está relacionada com o aumento de morbidade. O tremor aumenta o metabolismo, resultando em um acréscimo de 200% a 500% no consumo de oxigênio. CONTEÚDO: Discute as causas, a prevenção e o tratamento dos tremores intra- e pós-operatório em pacientes adultos e pediátricos submetidos à intervenção cirúrgica sob anestesia geral ou do neuroeixo. CONCLUSÕES: Os tremores são, juntamente com náuseas e vômitos, causas de intenso desconforto na sala de recuperação pós-anestésica, além de potencialmente prejudiciais por gerarem aumento da demanda metabólica. Embora a presença de tremores não tenha sido diretamente relacionada com a morbidade cardíaca, a prevenção tem se tornado tema de debate e de vários artigos científicos. A prevenção e o tratamento de tremores devem ser implementados. Pacientes com reserva cardiopulmorar limitada podem sofrer com acidose láctica, dessaturação venosa mista e hipoxemia.

Palavras-chave

ANESTESIA, COMPLICAÇÕES, TREMOR

Abstract

BACKGROUND AND OBJECTIVES: Tremors can be an adverse effect of the surgical intervention and anesthesia. The incidence of postoperative tremors varies from 6.3% to 66%. Young age, male gender, the use of halogenated anesthetics, and prolonged anesthesia or surgical procedure are related with tremors. Tremors are involuntary and present as oscillating muscular activity aiming at increasing heat production. Postoperative tremors are a disagreeable complication related with increased morbidity. Tremors increase the metabolism, resulting in a 200% to 500% increase in oxygen consumption. CONTENTS: The objective of this paper was to discuss the causes, prevention, and treatment of intra- and postoperative tremors in adults and children undergoing general anesthesia or neuroaxis anesthesia for surgical interventions. CONCLUSIONS: Tremors, along with nausea and vomiting, cause severe discomfort in the recovery room, besides being highly prejudicial because they generate an increase in the metabolism. Although the presence of tremors has not been directly related with cardiac morbidity, its prevention has become the subject of discussion and several scientific reports. Prevention and treatment of tremors should be implemented. Patients with limited cardiovascular reserve could develop lactic acidosis, mixed venous desaturation, and hypoxemia.

Keywords

ANESTHESIA, COMPLICATIONS, TREMOR

References

Frank SM, Beattie C, Christopherson R. Epidural versus general anesthesia, ambient operation room temperature, and patient age as predictors of inadvertent hypothermia. Anesthesiology. 1992;77:252-257.

Kurz A, Sessler DI, Narzt E. Postoperative hemodynamic and thermoregulatory consequences of intraoperative core hypothermia. J Clin Anesth. 1995;7:359-366.

Kranke P, Eberhart LH, Roewer N. Postoperative shivering in children: a review on pharmacologic prevention and treatment. Paediatr Drugs. 2003;5:373-383.

Buggy D, Higgins P, Moran C. Clonidine at induction reduces shivering after general anaesthesia. Can J Anaesth. 1997;44:263-267.

Piper SN, Röhm KD, Suttner SW. A comparison of nefopam and clonidine for the prevention of postanaesthetic shivering: a comparative, double-blind and placebo-controlled dose-ranging study. Anaesthesia. 2004;59:559-564.

Ciofolo MJ, Clergue F, Devilliers C. Changes in ventilation, oxygen uptake, and carbon dioxide output during recovery from isoflurane anesthesia. Anesthesiology. 1989;70:737-741.

Singh P, Dimitriou V, Mahajan RP. Double-blind comparison between doxapram and pethidine in the treatment of postanaesthetic shivering. Br J Anaesth. 1993;71:685-688.

Mathews S, Al Mulla A, Varghese PK. Postanaesthetic shivering a new look at tramadol. Anaesthesia. 2002;57:394-398.

Piper SN, Suttner SW, Schimdt CC. Nefopam and clonidine in the prevention of postanaesthetic shivering. Anaesthesia. 1999;54:695-699.

Buggy DJ, Crossley AW. Thermoregulation, mild perioperative hypothermia and postanaesthetic shivering. Br J Anaesth. 2000;84:615-628.

Lienhart A, Fiez N, Deriaz H. Frisson postoperatoire: analyse des principaux facteurs associes. Ann Fr Anesth Reanim. 1992;11:488-495.

Sessler DI, Rubinstein EH, Moayeri A. Physiologic responses to mild perianesthetic hypothermia in humans. Anesthesiology. 1991;75:594-610.

Horn EP. Postoperative shivering: aetiology and treatment. Curr Opin Anaesthesiol. 1999;12:449-453.

Camus Y, Delva E, Just B. Leg warming minimizes core hypothermia during abdominal surgery. Anesth Analg. 1993;77:995-999.

De Witte J, Sessler DI. Perioperative shivering: physiology and pharmacology. Anesthesiology. 2002;96:467-484.

Akin A, Esmaoglu A, Boyaci A. Postoperative shivering in children and causative factors. Paediatr Anaesth. 2005;15:1089-1093.

Crossley AW. Peri-operative shivering. Anaesthesia. 1992;47:193-195.

Panzer O, Ghazanfari N, Sessler DI. Shivering and shivering-like tremor during labor with and without epidural analgesia. Anesthesiology. 1999;90:1609-1616.

Horn EP, Sessler DI, Standl T. Non-thermoregulatory shivering in patients recovering from isoflurane or desflurane anesthesia. Anesthesiology. 1998;89:878-886.

Horn EP, Schroeder F, Wilhelm S. Postoperative pain facilitates nonthermoregulatory tremor. Anesthesiology. 1999;91:979-984.

Crossley AW. Six months of shivering in a district general hospital. Anaesthesia. 1992;47:845-848.

Alfonsi A, Nourredine KE, Adam F. Effect of postoperative skin-surface warming on oxygen consumption and the shivering threshold. Anaesthesia. 2003;58:1228-1234.

Sessler DI. Mild perioperative hypothermia. New England J Med. 1997;336:1730-1737.

Stapelfeldt C, Lobo EP, Brown R. Intraoperative clonidine administration to neurosurgical patients. Anesth Analg, 2005. 2005:226-232.

Bernard SA, Gray TW, Buist MD. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypotermia. N Engl J Med. 2002;346:557-563.

Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002;346:549-556.

Nolan JP, Morley PT, Vanden Hock TL. Therapeutic hypothermia after cardiac arrest: an advisor statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation. Circulation. 2003;108:118-121.

Horn EP, Werner C, Sessler DI. Late intraoperative clonidine administration prevents postanesthetic shivering after total intravenous or volatile anesthesia. Anesth Analg. 1997;84:613-617.

Matsukawa T, Sessler DI, Sessler AM. Heat flow and distribution during induction of general anesthesia. Anesthesiology. 1995;82:662-673.

Matsukawa T, Sessler DI, Christensen R. Heat flow and distribution during epidural anesthesia. Anesthesiology. 1995;83:961-967.

Eberhart LH, Doderlein F, Eisenhardt G. Independent risk factors for postoperative shivering. Anest Analg. 2005;101:1849-1857.

Xiong J, Kurz A, Sessler DI. Isoflurane produces marked and nonlinear decreases in the vasoconstriction and shivering thresholds. Anesthesiology. 1996;85:240-245.

Matsukawa T, Kurz A, Sessler DI. Propofol linearly reduces the vasoconstriction and shiverig thresholds. Anesthesiology. 1995;82:1169-1180.

Lee DS, Shaffer MJ. Low incidence of shivering with chronic propranolol therapy. Lancet. 1986;1.

Cheng C, Matsukawa T, Sessler DI. Increasing mean skin temperature linearly reduces the core-temperature thresholds for vasoconstriction and shivering in humans. Anesthesiology. 1995;82:1160-1168.

Crossley AW, Mahajan RP. The intensity of postoperative shivering is unrelated to axillary temperature. Anaesthesia. 1994;49:205-207.

Holdcroft A, Hall GM. Heat loss during anaesthesia. Br J Anaesth. 1978;50:157-164.

Lyons B, Taylor A, Power C. Postanaesthetic shivering in children. Anaesthesia. 1996;51:442-445.

Vaughan MS, Vaughan RW, Cork RC. Postoperative hypothermia in adults: relationship of age, anesthesia, and shivering to rewarming. Anesth Analg. 1981;60:746-751.

Miyaguchi M, Kobayashi A, Iwaki H. Human monocyte response to retrieved polymethylmethacrylate particles. J Biomed Mater Res. 2002;62:331-7.

Kranke P, Eberhart LH, Roewer N. Pharmacological treatment of postoperative shivering: a quantitative systematic review of randomized controlled trials. Anesth Analg. 2002;94:453-460.

Crossley AW. Postoperative shivering: the influence of body temperature. BMJ. 1995;311:764-765.

Buggy D, Hughes N. Pre-emptive use of the space blanket reduces shivering after general anaesthesia. Brit J Anaesth. 1994;72:393-396.

Gordon CJ, Heath JE. Integration and central processing in temperature regulation. Ann Rev Phsiol. 1986;48:595-612.

Sessler DI, Esrael D, Pozos RS. Spontaneous postanesthetic tremor does not resemble thermoregulatory shivering. Anesthesiology. 1988;68:843-850.

Annadata R, Sessler DI, Tayefeh F. Desflurane slightly increases the sweating threshold, but produces marked and non-linear decreases in the vasoconstriction and shivering thresholds. Anesthesiology. 1995;83:1205-1211.

Cheong KF, Low TC. Propofol and postanesthetic shivering. Anaesthesia. 1995;50:550-552.

Frank SM, Fleisher LA, Breslow MJ. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events: a randomized clinical trial. JAMA. 1997;277:1127-1137.

Pestel GJ, Kurz A. Hypothermia: it's more than a toy. Curr Opin Anesthesiol. 2005;18:151-156.

Lopez M, Selsser DI, Walter K. Rate and gender dependence of the sweating, vasoconstriction, and shivering thresholds in humans. Anesthesiology. 1994;80:780-788.

Macintyre PE, Pavlin EG, Dwersteg JF. Effect of meperidine on oxygen consumption, carbon dioxide production, and respiratory gas exchange in postanesthesia shivering. Anesth Analg. 1987;66:751-755.

Greif R, Laciny S, Rajek A. Blood pressure response to thermoregulatory vasoconstriction during isoflurane and desflurane anesthesia. Acta Anaesthesiol Scand. 2003;47:847-852.

Piper SN, Maleck WH, Boldt J. A comparison of urapidil, clonidine, meperidine and placebo in preventing postanesthetic shivering. Anesth Analg. 2000;90:954-957.

Milam SB, Bennett CR. Physostigmine reversal of drug-induced paradoxical excitement. Int J Oral Maxillofac Surg. 1987;16:190-193.

Vanderstappen I, Vandermeersch E, Vanacker B. The effect of prophylactic clonidine on postoperative shivering: a large prospective double-blind study. Anaesthesia. 1996;51:351-355.

Wrench IJ, Cavill G, Ward JE. Comparison between alfentanil, pethidine and placebo in the treatment of post-anaesthetic shivering. Br J Anaesth. 1997;79:541-542.

Terasako K, Yamamoto M. Comparison between pentazocine, pethidine and placebo in the treatment of post-anaesthetic shivering. Acta Anaesthesiol Scand. 2000;44:311-312.

Sharma DR, Thakur JR. Ketamine and shivering. Anaesthesia. 1990;45:252-253.

Delaunay L, Bonnet F, Liu N. Clonidine comparably decreases the thermoregulatory thresholds for vasoconstriction and shivering in humans. Anesthesiology. 1993;79:470-474.

Powell RM, Buggy DJ. Ondansetron given before induction of anesthesia reduces shivering after general anesthesia. Anesth Analg. 2000;90:1423-1427.

Pappata S, Tavitian B, Traykov L. In vivo imaging of human cerebral acetylcholinesterase. J Neurochem. 1996;67:876-879.

Horn EP, Standl T, Sessler DI. Physostigmine prevents postanesthetic shivering as does meperidine or clonidine. Anesthesiology. 1998;88:108-113.

Latasch L, Müller B, Freye E. Routinemassige gabe von Physostigmin hat fur die postoperative phase keine bedeutung-eine randomisierte untersuchung zur vigilans zum kreislaufverhalten, muskelzitten und schmerzmittelbedarf. Anasthesiol Intensivmed Notfallmed Schmerzth. 2003;38:528-537.

Risch SC, Janowsky DS, Mott MA. Central and peripheral cholinesterase inhibition: effects on anterior pituitary and syjmpathomimetic function. Psychoneuroendocrinology. 1986;11:221-230.

Kranke P, Eberhart LH, Roewer N. Single-dose parenteral pharmacological interventions for the prevention of postoperative shivering: a quantitative systematic review of randomized controlled trials. Anesth Analg. 2004;99:718-727.

Kurz A, Ikeda T, Sessler DI. Meperidine decreases the shivering threshold twice as much as the vasoconstriction threshold. Anesthesiology. 1997;86:1046-1054.

Nicolaou G, Chen AA, Johnston CE. Clonidine decreases vasoconstriction and shivering thresholds, without affecting the sweating threshold. Can J Anaesth. 1997;44:636-642.

Eberhart LH, Novatchkov N, Schricker T. Clonidin in vergleich zu midazolam zur intravenosen pramedikation von ambulatenten eingriffen: Eine kontrollierte doppelblindstudie bei ASA 1-patienten. Anasthesiol Intensivmed Notfallmed Schmerzther. 2000;35:388-393.

Sia S. I.V. clonidine prevents post-extradural shivering. Br J Anaesth. 1998;81:145-146.

Vanderstappen I, Vandermeersch E, Vanacker B. The effect of prophylactic clonidine on postoperative shivering: a large prospective double-blind study. Anaesthesia. 1996;51:351-355.

Weinbroum AA, Geller E. Flumazenil improves cognitive and neuromotor emergence and attenuates shivering after halothane, enflurane and isoflurane-based anesthesia. Can J Anaesth. 2001;48:963-972.

Dal D, Kose A, Honca M. Efficacy of prophylactic ketamine in preventing postoperative shivering. Br J Anaesth. 2005;95:189-192.

Rohm KD, Riechmann J, Boldt J. Physostigmine for the prevention of postanaesthetic shivering following general anaesthesia a placebo-controlled comparasion with nefopan. Anaesth. 2005;60:433-438.

Hong JY, Lee IH. Comparison of the effects of intrathecal morphine and pethidine on shivering after caesarean delivery under combined spinal epidural. Anaesthesia. 2005;60:1168-1172.

Abreu MP, Vieira JL, Lutti MN. Incidência de tremor em anestesia com ou sem fentanil: estudo comparativo. Rev Bras Anestesiol. 2004;54:153-161.

Wrench IJ, Singh P, Dennis AR. The minimum effective doses of pethidine and doxapram in the treatment of post-anaesthestic shivering. Anaesthesia. 1997;52:32-36.

Tsai YC, Chu KS A. comparation of tramadol, amitriptyline, and meperidine for postepidural anesthetic shivering in parturients. Anesth Analg. 2001;93:1288-1292.

Alfonsi P, Adam F, Passard A. Nefopam a nonsedative benzoxazocine analgesic, selectively reduces the shivering threshold in unanesthetized subjects. Anesthesiology. 2004;100:37-43.

Stevens RD, Burri H, Tramèr MR. Pharmacologic myocardial protection in patients undergoing noncardiac surgery: a quantitative systematic review. Anesth Analg. 2003;97:623-633.

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