1 - Anaesthesia , Pain & Intensive Care

114 Pages·2013·2.33 MB·English

ANAESTHESIA, PAIN
& INTENSIVE CARE
An International Journal of Anesthesiology, Pain Management, Intensive Care & Resuscitation
Vol. 17 No. 1 January - April 2013
Patron: Associate Editors: Statistician
Brig. M. Salim. SI(M) Zahid Akhtar Rao Irum Abid
Professor of Anesthesiology Associate Prof. of Anaesthesia,
President STSP Bahria Univ. Medical & Dental
[email protected] College, Karachi (Pakistan) Editorial Board:
[email protected] Arshad Taqi (Pakistan)
Editor-in-Chief:
Dario Galante (Italy)
Tariq Hayat Khan Fares Chedid
Fazal Hameed (Pakistan)
Consultant Anesthesiologist Consultant Neonatologist
& Pain Specialist Tawam Hospital, Al Ain, Gauhar Afshan (Pakistan)
Vice President STSP Abu Dhabi (UAE) Joseph D. Tobias (USA)
[email protected] [email protected]
Khalid Bashir (Pakistan)
Koji Sumikawa (Japan)
Editors: Assistant Editors:
Samina Ismail Pranav Bansal (India) Mohamad Said Ahmad Maani
Associate Prof. of Anaesthesia, [email protected] Takrouri (Saudi Arabia)
AKUH Karachi.
Pramila Bajaj (India)
[email protected] Muhammad Faisal Khan (KSA)
Rana Altaf Ahmad (Pakistan)
[email protected]
Said Abuhasna Rashed A. Hasan (USA)
Chairman, Dept. of Critical Care Amer Majeed (UK) Saeid Safari (Iran)
Medicine, Chief Intensive Care Unit, [email protected]
Shahab Naqvi (Pakistan)
Tawam Hospital, Al Ain,
S. K. Malhotra (India)
Abu Dhabi (UAE) Logan Danielson (USA)
[email protected] [email protected] Waqas Ahmed Qazi (Pakistan)
‘Anaesthesia, Pain & Intensive Care’ is indexed by PakMediNet,
Medlip. Index Medicus (EMR), EBSCO, Index Copernicus, Embase,
EMCare, UDL (Malaysia), DOAJ, Web Mèdica Acreditada Quality
Program (WMA), WMA Google Search.
Listed with: National Library of Medicine Catalogue NLM ID:
101313795 [Serial]; HINARI portal.
Registered by Pakistan Medical & Dental Council (PM&DC).
Recognized by Higher Education Commission (HEC)
Permission granted by District Magistrate Islamabad for publication.
General Information: The journal is published thrice a year in
the months of April, August and December. Please direct inquiries
regarding subscriptions, single copies and back issues, changes of
Cover Picture: “Siesta” 15th November 2010
addresses, and other correspondence to the Publications Office.
By: Dr Amer Majeed
Advertising inquiries should also be sent to the same address.
See us at FACE BOOK, Twitter, Linked in and Medpedia Regional Office (Pakistan): Dept of Anaesthesia and
All articles represent the opinions of the authors and do not reflect Pain Management, AKUH, Karachi.
official policy of the journal. All rights are reserved to the publisher. Ph: [phone]/4331
No part of the journal may be reproduced or transmitted in any form
or by any means, electronic or mechanical, including photocopying, Regional Office (UAE): Dept of Anaesthesia and
regarding, or via any retrieval system, without written permission from Critical Care, Tawam Hospital,
the publisher. P.O. Box 152858, Al-Ain, Abu Dhabi (UAE).
Subscription Rates: The rates for a one-year subscription of the Head Office: ‘APICARE’
Journal are Pak Rupees 1000 for subscribers in Pakistan, Pak Rupees 60-A, Nazim-ud-Din Road, F-8/4, Islamabad (Pakistan)
2000 for institutions in Pakistan, Pak Rupees 2000 for subscribers from E-mail: [email protected], [email protected]
SAARC countries and Pak Rupees 4000 from elsewhere. www.apicareonline.com Ph: [phone]
Published by: Dr. Tariq Hayat Khan
ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 Vol. 17 No. 1
coNTeNTs
eDIToRIAL VIeWs comparison of intravenous butorphanol, 33
ondansetron and tramadol for control of
Transfusion, under-transfusion and 1 shivering during regional anesthesia:
over-transfusion A prospective, randomized double-
Tariq Hayat Khan blind study
Joshi Smita Suresh, Adit Arora, Arun George,
can you stop this shivering doctor? 4 Shidhaye Ramchandra Vinayak,
Arshad Taqi
A cross-sectional study of knowledge 40
and attitudes of medical professionals
Postoperative nausea and 6
towards end-of-life decisions in teaching
vomiting (PoNV): A cause for concern
hospitals of Kandy District (sri Lanka)
Khalil Ullah Shibli
M.V.G. Pinto, R Varun, W. M. M. P. B. Wanasinghe, T. M. K.
Jayasinghearachchi, H. M. T. A Herath, P. V. R. Kumarasiri,
sPecIAL ARTIcLe
Use of a portable oxygen concentrator 45
Termination of ventilatory support of 10
and its effect on the overall functionality
a patient under compulsion, who is
of a remote field medical unit at 3650
not yet brain dead
meters elevation
S.K.Malhotra
Rehan Masroor, Amjad Iqbal, Khalid Buland,
Waqas Ahmad Kazi
oRIGINAL ARTIcLes
A retrospective seven years audit of 51
sedation with propofol during combined 14 mode of deliveries in a tertiary care
spinal epidural anesthesia: comparison university hospital of Turkey
of dose requirement of propofol with and
Berrin Gunaydin, Kadir Kaya
without BIs monitoring
A prospective, randomized, double-blind, 55
R. K. Verma, Anil K Paswan, Shashi Prakash,
comparative study of the efficacy of
Surender K. Gupta, P.K. Gupta
intravenous ondansetron and
palonosetron for prevention of
Does intra-cuff alkalinized lidocaine 18
postoperative nausea and vomiting
prevent tracheal tube induced
emergence phenomena in children? Bijaya Kumar Shadangi, Jitendra Agrawal, Rabindra Pandey,
Arvind Kumar, Sanjay Jain, Rakhi Mittal, H K Chorasia
Mona S. Ahmady, Sayed Sadek, Roshdi R. Al-metwalli
Diurnal variation of extremely low 59
Thoracic epidural for post-thoracotomy 22
frequency electromagnetic field in an
and thoracomyoplasty pain: a
empty operating room
comparative study of three concentrations
Jae Wook Jung, Yong Han Kim, Gwang Cheol Go,
of fentanyl with plain ropivacaine
Jae Hong Park, Sang Yoon Jeon, Sang Eun Lee, Sira Bang,
Ajay Kr Chaudhary, Dinesh Singh, Jai Shri Bogra,
Ki Hwa Lee, Ki Hoon Kim
Sulekha Saxena, Girish Chandra, Shashi Bhusan,
Prithvi Kr Singh sHoRT coMMUNIcATIoN
‘Maximum surgical Blood order 28 The prevalence of obstructive sleep 63
schedule’ in a newly set-up tertiary apnea characteristics in patients with
care hospital Barrett’s esophagus
R. Thabah, L. T. Sailo, J. Bardoloi, M. Lanleila, Medhat Hannallah, Yonette Exeter, Maggie Gillespie,
N. M. Lyngdoh, M. Yunus, P. Bhattacharyya Jason Hoefling
ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 Vol. 17 No. 1
coNTeNTs
ReVIeW ARTIcLe Airway management in a patient with a 97
large mass in scapular region:
Prehospital trauma care services in 65 A case report
developing countries
Haidar Abbas, Zia Arshad, Sulekha Saxena, Jai Shree Bogra
Lakesh Kumar Anand, Manpreet Singh, Dheeraj Kapoor
LeTTeR To eDIToR
cAse RePoRTs
Valsalva maneuver aids blind central 100
successful intubation with air-Q in 71 venous catheterization
Pierre Robin syndrome
Sukhen Samanta and Rudrashish Haldar
Tariq Hayat Khan, Amna Ghayas, Ayesha,
Samreen Khushbakht, Adeel Ahmed, Naeem Khan Accidental intra arterial injection of 101
diclofenac sodium and consequences:
Anesthetic considerations in Morquio 75 report of two cases
syndrome: A case report
Sukhen Samanta and Rudrashish Haldar
Thorat Pravin Shivajirao, Nageshkumar P Wasmatkar,
Pratibha Govindrao Gore, J. N. Lakhe, TReNDs & TecHNoLoGy 103
Shidhaye Ramchandra Vinayak,
cLINIQUIZ
challenges during prolonged mechanical 79
ventilation of a morbidly obese lady with
Acute respiratory distress syndrome 104
hypothyroidism and sleep apnea
Pranav Bansal, Gaurav Jain, Meenu Agarwal,
syndrome
Karamveer Singh
Saurabh Kumar Das, D. K. Singh, Sujali Choupoo,
Ghanshyam Yadav, cALeNDAR oF eVeNTs 106
Dexmedetomidine and the perioperative 83 cLINIPIcs
care in Riley-Day syndrome: a case
report and literature review optimising the length of i-gel 108
Matthew DiGiusto, David Martin, Joseph D. Tobias Tariq Hayat Khan, Amna Ghayas, Ayesha,
Shiraz Naeem, Naeem Khan
successful treatment of severe Legionella 88
‘My Most Memorable Patient’® 54
pneumonia and acute kidney injury with
polymyxin B-immobilized fiber column Nabil Estemalik
direct hemoperfusion
Yasunari Matsuki, Yuka Matsuki, Yoshikazu Yasuda,
‘My Most Unforgettable experience’® 107
Maki Mizogami, Ko Takakura, Kenji Shigemi
Me and my fibromyalgia
Accidental asphyxiation by an Arabic 91 Valerie Lumley
headscarf
Said D. Abuhasna, Mustafa Abu Ebaid,
Eman D.M. Qadoom, Masood Ur Rahman
Failed ventilation with LMA Proseal® in 94
a patient with sleep apnea syndrome
Anju Ghai, Sarla Hooda, Raman Wadhera, , Nandita Kad,
Nidhi Garg
Instructions for authors
The ‘APICARE’ agrees to accept manuscripts prepared in ac- cm) in size. These may be in black and white or in colour. Nega-
cordance with the ‘Uniform Requirement for Submission of tives, transparencies, and X-ray films should not be submitted.
Manuscripts Submitted to Biomedical Journals’ published in the The number of the figure, the name of the author(s) should be
British Medical Joumal 1991 ;302:334N1, All material submitted printed on the back of each figure/photograph, and must be cit-
for publication should be sent exclusively to the ‘APICARE’. ed in the text in consecutive order. Legends must be typed on a
separate sheet of paper. Legends for photographs should indicate
ETHICAL CONSIDERATIONS: If tables, illustrations or
the magnification, internal scale and the method of staining. Pho-
photographs, which have been already published, are included,
tographs in published articles will not be returned.
a letter of permission for their re-publication should be obtained
from author(s) as well as the editor of the journal where it was REFERENCES: Should be numbered in the order in which
previously printed. Permission to reproduce photographs of pa- they are cited in the text. At the end of the article, the full list
tients whose identity is not disguised should be sent with the of references should give the names and initials of all authors
manuscript otherwise the eyes will be blackened out. (unless there are more than six when only the first six should be
given followed by et al). The authors’ names are followed by the
MATERIAL FOR PUBLICATION: The material submitted
title of the article; the title of the journal abbreviated according
for publication may be in the form of an Original Research, a Re-
to the style of the Index Medicus. e.g.: Hall, RR. The heading
view Article, a Case Report, Recent Advances, New Techniques,
of tissues by CO laser. Br J. Surg 1971; 58:222-225. Reference
Debates, Book Review/CDs on Clinical/Medical Education, or 2
to books should give the names of editors, place of publication,
a Letter to the Editor. Original articles should normally report
publisher, and year.
original research of relevance to clinical anaesthesiology, pain
management, intensive care or resuscitation, and may appear ei- PEER REVIEW: Every paper will be reviewed by a member
ther as a paper or as short communications. The paper should of the editorial committee, and one or more external reviewers.
be of about 2000 words, with no more than six tables or illus- Statistical analysis wail be examined by a statistician.
trations, short communications should be of about 600 words,
ABSTRACT: Abstracts of onginal article should be prepared
with one table or illustration and no more than five references.
with a structured format. The elements addressed could include
Clinical case reports and brief or negative research findings may
objectives, design, setting, patients or other participants, inter-
appear in this section. Review article should consist of structured
ventions, and outcome measures, the results, and conclusions.
overview of some relatively narrow topic providing background,
Please label each section clearly with the appropriate subheading.
recent development with reference to original literature.
Review article, Case report and other require a short, unstruc-
Letters should normally not exceed 400 words, have no more tured abstract Commentaries do not require abstract. A list of
than 10 references, and be signed by all of the authors. An article key words should be given consisting of MeSH terms.
based on dissertation submitted as part of the requirement for a
INTRODUCTION: This should include the purpose of the ar-
fellowship of the postgraduate degree awarding medical institu-
ticle. The rationale for the study or observation should be sum-
tions can be sent for publication after the Research and Training
marised; only strictly pertinent references should be cited; the
Monitoring Cell (RTMC) have approved it. Editorials are writ-
subject should not be extensively reviewed Data or conclusions
ten by invitation.
from the work being reported should not be presented.
Each manuscript should include a title page (containing e-mail
METHODOLOGY: The selection of the observational or ex-
address, fax and phone numbers of the corresponding author),
perimental subjects (patients or experimental animals, including
abstract, text, acknowledgments, references, tables, and legends.
controls) should be described clearly in the methods and the ap-
Each component should begin on a new page, in the following paratus used should be identified (with the manufacturers name
sequence: title page: abstract and keywords: text; acknowledg- and address in parentheses), and procedures described in suffi-
ments; references; tables (each table, complete with title and cient detail to allow other workers to reproduce the results Ref-
footnotes, on a separate page); and legends for illustrations. erences to established methods should be given, including statis-
tical methods; references and brief descriptions for methods that
The manuscript should be typed in double spacing on 8 ½″ x 11″
have been published but are not wall known should be provided;
(21.5cm x 28.0cm) white bond paper with one-inch (2.5cm) mar-
new or substantially modified methods should be described, giv-
gin on both sides. It should not exceed 20 pages, excluding tables
ing reasons for using them, and evaluating their limitations. All
and references. There should be no more than 40 references in an
drugs and chemicals used should be identified precisely, includ-
Original Article, and no more than 100 in a Review Article.
ing generic name(s), dose(s), and route(s) of administration.
TABLES AND ILLUSTRATIONS: Tables and illustrations
RESULTS: These should be presented in a logical sequence in
should be submitted separately, and legends to illustrations
the text, tables, and illustrations. All the data in the tables or
should be typed on a separate sheet. Each table should have a
illustrations should not be repeated in the text; only important
title and be typed in double space without horizontal and verti-
observations should be emphasized or summarised.
cal lines on an 8 ½″ x 11″ (21.5 x 28.0 cm) paper. Tables should be
numbered consecutively with Roman numerals in the order they DISCUSSION: The authors comments on the results, sup-
are mentioned in the text. Page number should be in the upper ported with contemporary references, including arguments and
right corner, if abbreviations are used, they should be explained analysis of identical work done by other workers. A summary is
in footnotes. When graphs, scatter grams, or histograms are sub- not required. Brief acknowledgment may be made at the end.
mitted, the numerical data on which they are based should be
ONLINE SUBMISSION: The manuscripts maybe submitted
supplied.
online via our website www.apicareonline.com or sent as e-mail
S.I. UNITS: System Intemational (Sl) Unit measurements should attachments to the head office or one of the regional offices.
be used. All drugs must be mentioned in generic form. The com- Pictures must be sent separately as JPEG or in TIFF format.
mercial name may, however, be mentioned with in brackets. Submission of scanned copies of the tables, diagrams, Graphs,
and Pictures is not acceptable. Model submission letter maybe
FIGURES AND PHOTOGRAPHS: Should be sent only
downloaded from the website, duly filled in, signed by all of the
when data cannot be expressed in any other form. These must
authors and must be submitted along with the manuscript.
be unmounted, glossy prints in sharp focus, 5″ x 7″, (12.7 x 17.3

eDIToRIAL VIeW
Transfusion, under-transfusion and
over-transfusion
Tariq Hayat Khan, MBBS, MCPS, FCPS
Consultant anesthesiologist, Department of anesthesiology, KRL General Hospital, G-9/1, Islamabad (Pakistan)
Correspondence: Dr. Tariq Hayat Khan, FCPS, Consultant anesthesiologist, H. No. 163, Street 53, G-10/3, Islamabad
(Pakistan); Cell: [phone]; E-mail: [email protected]
SUMMARY
The incidence of transfusion has increased day by day due to many factors, including increasing population,
enhanced expertise and facilities to operate once inoperable conditions and the willingness of the public to pay
high cost of advanced surgical procedures. Trauma services have been well-organized now and victims may have
massive transfusion. Many authors have pointed out the need of protocols and guidelines to be followed to avoid
transfusion associated risks and complications. Under-transfusion has been preferred to over-transfusion and a
need to have a ‘Maximum Surgical Blood Order Schedule’ has been stressed.
Key words: Blood transfusion; Massive transfusion; Over-transfusion; Under-transfusion; Transfusion-related
acute lung injury; TRALI; Transfusion-associated circulatory overload; TACO
Citation: Khan TH. Transfusion, under-transfusion and over-transfusion. Anaesth Pain & Intensive Care
2013;17(1):1-3
Blood transfusion is in practice for many decades, but patient with asymptomatic anemia and it may be
it has been associated with some controversies since pharmacologically treatable with folate, vitamin B , or
12
its start. Before the era of the advent of current cross- iron, in which case transfusion can be avoided. In our
matching techniques and before the advanced screening practice we have noted a persistent Hb level below 10
techniques for bacterial and viral contamination, it led gm in pregnant ladies of our population. Levels between
to immeasurable morbidity and mortality. Still, the 7-9 are the most common finding, and blood needed
number of transfusions has steadily increased over the to be transfused very rarely during cesarean sections.
last three or four decades throughout the world, a 128% This transfusion avoidance strategy can be applied to
growth rate between 1997 and 2009.1 The progress in inpatients as well. A patient who was leading an active
cardiothoracic, neurosurgery and trauma surgery plus life and was completely asymptomatic at a Hb level of
establishment of blood banks and transfusion services 7 gm, will hopefully tolerate a blood loss of 400-500 ml
has played a major positive role in this increase. In during her cesarean section.
the United States, more than 15 million units of RBCs
Many international societies and associations have
are transfused annually.2 The Agency for Healthcare
formulated clinical practice guideline for transfusion,
Research and Quality (AHRQ) reports that blood
recommending a restrictive transfusion strategy, i.e.,
transfusion is the most frequently performed procedure
considering transfusion only at a hemoglobin level of
for inpatients.1 Medical research is continuing in search
less than 7 to 8 g/dl in hospitalized, stable patients.7 The
of good and more appropriate protocols and guidelines
Joint Commission has proposed National Patient
to regulate transfusion practices, as many researchers
Safety Goal 16.01.01 “to minimize the overuse of tests,
have pointed out that the current trend favors
treatments, and procedures to reduce the risk of patient
inappropriate or unjustified transfusion.3
harm.”8
The questions, ‘At what point you would start
Although there is a thin line between massive transfusion
transfusion’ and ‘how much’ must be asked before
and over-transfusion, for all practical purposes, the risks
ordering transfusion. An increased morbidity and
associated with blood transfusion are multiplied with
mortality has been observed in patients who are
both of these. Massive transfusion is usually defined
transfused at a higher rather than a lower hemoglobin
as the use of ten or more bags of blood in a single
(Hb) threshold.4-6 Blood may not be needed in every
patient; whereas, over-transfusion can be described as
ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 1
transfusion issues
the practice of transfusing blood or blood products in data from the New York State Department of Health
excess of the actual and genuine needs of the patient. errors database, Linden and colleagues reported that
MT may not always be justified in most of the critical the risk of mistransfusion was one in every 12,000
situations, when reasonable estimate of blood loss is procedures.15 ABO-incompatible mistransfusions occur
difficult or impracticable. The anesthesiologists and at a rate of 1 in every 33,000 procedures, with 1 in every
the surgeons usually depend upon visual estimates for 600,000 resulting in death.15 The Joint Commission has
ordering blood and have a tendency to over-transfuse had patient identification as the number one National
in emergency related confusion. Patient Safety Goal (NPSG) for many years. In the
2012 National Patient Safety Goals, TJC has added
Over-transfusion still continues on an international
NPSG 01.03.01 to eliminate transfusion errors related
level. Although the risk of transfusion-transmitted
to patient misidentification.16
diseases has greatly reduced, with the following current
rates: HIV, 1 transmission in every 2 million units; Under-transfusion may be defined as transfusing
hepatitis C virus (HCV), 1 in every 2 million units blood in a volume less than that estimated to be
and hepatitis B virus (HBV), 1 in every 200,000 units required for a particular patient. Careful estimation
transfused, bacterial contamination of platelets continues of the intraoperative blood loss will guide us towards
to carry a high risk at 1 in 2,000 units transfused.9,10 The projected Hb after all that hemodilution by crystalloids
problem is not confined to transmission of disease and/or colloids. Blood loss may be justified to be fully
only, transfusion-related acute lung injury (TRALI) compensated in neonatal and pediatric surgery, many
and transfusion-associated circulatory overload anesthesiologists will rely upon their visual assessment
(TACO), both noninfectious conditions, are the two and transfuse if absolutely essential. Postoperative Hb
leading causes of fatalities associated with transfusion. estimate may be a better guide to replace blood loss.
The risk of all these increases with every bag of blood Under-transfusion has many advantages; less risk of
transfused. We need to ensure that the indication of spread of blood related infections, less risk of transfusion
blood transfusion for each patient is evidence-based errors, avoidance of TRALI and TACO, and less
and consistent with current guidelines. financial burden on the patient. It will be tolerated
by many patients except patients of cardiovascular
The anesthesiologists are well aware that stored blood
disease. Anemia is the worst enemy of cardiac patients
cells undergo multiple biochemical, functional, and
due to associated circulatory overload. A study about
structural changes, a condition referred to as the
perioperative cardiac morbidity in 1990 stated that of the
RBC storage lesion, and that 2,3-diphosphoglycerate (2,3-
25 million patients undergoing noncardiac surgery each
DPG) decreases in these, shifting the oxyhemoglobin
year in the United States, approximately one third, or 8
dissociation curve to the left, making these less efficient
million are at risk for cardiac morbidity or mortality.17
in delivering oxygen to the tissues. Stored cells have
Many of these patients will also be anemic, whether
insufficient nitric oxide (NO) bioavailability, which
due to acute blood loss (surgery or trauma) or chronic
also results in vasoconstriction and decreased oxygen
conditions such as renal failure or cancer. Attempts to
delivery.11 Transfusing RBCs, stored for more than
limit the volume of allogeneic blood transfused have
2 weeks, have been associated with a statistically
focused on tolerance of lower hemoglobin levels, but
significant risk of postoperative complications,
such a practice may increase risk in these patients. No
including increased mortality, prolonged ventilator
doubt, in the perioperative period, the most commonly
support, increased renal failure, and sepsis.12
cited risk factors for adverse cardiac outcomes are
It is reasonable to assume that the incidence of
gender, age, urgency of operation, and the presence of
transfusion errors will be increased with massive
existing congestive heart failure, diabetes or significant
transfusion or over-transfusion. Most of these are
cerebral vascular occlusive disease.18
caused by patient caregivers outside the laboratory and
Patients without coronary artery disease, have a
a lesser number by the hospital transfusion service.
tremendous ability to compensate for decreases in
Surprisingly, phlebotomy has been found to account
coronary arterial oxygen content; patients with
for 13% of all transfusion-associated errors.13 A study
coronary artery disease have a limited ability to
reviewing 4,000 transfusion audits from the College of
compensate for or to tolerate uncompensated decreases
American Pathologists Q-Probe data revealed that in
in myocardial oxygen delivery, and there is a narrow
25% of transfusions, the transfusionist failed to confirm
window of Hb or hematocrit values at which these
patient identification.14 Missed identification may lead
patients do the best. Hematocrit values below 28%
to mistransfusion. Mistransfusion, the transfusion of
or above 35% appear to be associated with increasing
a unit of blood to the wrong patient, is the leading
risk of morbidity and mortality whether in chronic or
cause of mortality associated with transfusion. Using
2 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013
editorial view
acute anemia. of the critical Hb or hematocrit at which ischemia will
develop in any given patient.
Jehovah’s Witnesses have provided great opportunity
To control the over-judicious crossmatch orders, and
to the researchers to study the effects of anemia and
over-transfusion, strict blood utilization criteria need
the tolerance of blood loss during trauma or surgery.
to be enforced in every hospital. The common practice
In a study of 125 such patients undergoing surgery,
of ordering two units of blood has to be changed in
both intraoperative blood loss and perioperative
favour of ordering a single unit at a time, and type
Hb levels were found to be independent predictors
and crossmatch orders need to be abandoned in favor
of postoperative mortality (rising from 6% at Hb
of type and screen. Some departments insist that
levels of >8 g/dl to 61% at Hb levels of <6 g/dl).19
crossmatch orders must mention documented clinical.
Another study provided contradictory evidence, citing
A periodic review of the existing protocols and the
children of Jehovah’s Witnesses with HB levels of 3 g/
practices is recommended for maximum optimization.
dl tolerating bypass without difficulty18. A final study
The protocols may differ from time to time within a
of the association between anemia and mortality in
single institution or from institution to institution.
Jehovah’s Witnesses reported that blood loss of >500
The study by Thabah R et al21 in this issue of the
ml during surgery was a more important risk factor
journal emphasizes the need of proper assessments of
than was preoperative Hb.20
the requirement of blood and blood products in every
There is little clinical evidence that permits prediction institution. Protocols need to be made and adhered to.
REFERENCES
1. Health Cost and Utilization Project. Statistics 26, 2012]. Ann Intern Med. http://www.annals. study of patient identification and vital sign
on Hospital-based Care in the United States, org/content/early/2012/03/26/0003-4819-156- monitoring frequencies in 16,494 transfusions.
2009. Washington, DC: Agency for Healthcare 12-201206190-00429.long. Accessed July 2, Arch Pathol Lab Med. 2003;127(5):541-548.
Research and Quality; 2011. [Access Online] 2012. [Medline] [Free Full Text]
2. Office of the Assistant Secretary of Health. The 8. The Joint Commission. Critical Access Hospital 15. Linden JV, Paul B, Dressler K. A report of
2009 National Blood Collection and Utilization Accreditation Program. Proposed national 104 transfusion errors in New York State.
Survey Report. Washington, DC: Department patient safety goal 16.01.01. http://www. Transfusion. 1992;32(7):601-606. [Medline]
of Health and Human Services; 2011. [Access jointcommission.org/assets/1/6/CAH_NPSG_ 16. The Joint Commission. Hospital Accreditation
Online] Overuse_Rpt_2011-11-14.pdf. Accessed July Program. National patient safety goals
3. Rothschild JM, McGurk S, Honour M, et al. 2, 2012. effective January 1, 2012. NPSG 01.03.01.
Assessment of education and computerized 9. National Heart Lung and Blood Institute. What http://www.jointcommission.org/assets/1/6/
decision support interventions for improving are the risks of a blood transfusion?http:// NPSG_Chapter_Jan2012_HAP.pdf. Accessed
transfusion practice. Transfusion. www.nhlbi.nih.gov/health/health-topics/topics/ July 2, 2012.
2007;47(2):228-239. [Medline] bt/risks.html. Published January 30, 2012. 17. Mangano DT. Perioperative cardiac morbidity.
4. Hébert PC, Well G, Blajchman MA, et al. A Accessed July 2, 2012. Anesthesiology 1990;72(1):153-84. [Medline]
multicenter, randomized, controlled clinical 10. Centers for Disease Control and Prevention. 18. Cosgrove DM, Loop FD, Lytle BW, Baillot R ,
trial of transfusion requirements in critical care. Blood safety. http://www.cdc.gov/bloodsafety/ Gill CC, Golding LA et al. Primary myocardial
N Engl J Med. 1999;340(6):409-417. [Medline] bbp/diseases_organisms.html. Updated May revascularization. Trends in surgical mortality.
[Free Full Text] 8, 2012. Accessed July 2, 2012. J Thorac Cardiovasc Surg 1984;88(5 Pt
5. De Oliveira GS Jr, Schink JC, Buoy C, et al. The 11. Roback JD. Vascular effects of the red blood 1):673-84. [Medline]
association between allogeneic perioperative cell storage lesion. Hematology Am Soc 19. Carson JL, Poses RM, Spence RK, Bonavita G.
blood transfusion on tumour recurrence and Hematol Educ Program 2011;2001:475-479. Severity of anaemia and operative mortality and
survival in patients with advanced ovarian [Medline] [Free Full Text] morbidity. Lancet 1988;1(8588):727-9. [Medline]
cancer. Transfus Med. 2012;22(2):97- 12. Koch CG, Li L, Sessler DI, et al. Duration of 20. Spence RK, Carson JA, Poses R, McCoy S,
103. [Medline] red-cell storage and complications after cardiac Pello M, Alexander J, et al. Elective surgery
6. Paone G, Brewer R, Theurer PF, et al. surgery. N Engl J Med. 2008;358(12):1229- without transfusion: influence of preoperative
Preoperative predicted risk does not fully 1239. [Medline] [Free Full Text] hemoglobin level and blood loss on mortality.
explain the association between red blood cell 13. Linden JV, Wagner K, Voytovich A, Sheehan Am J Surg 1990;159(3):320-4. [Medline]
transfusion and mortality in coronary artery J. Transfusion errors in New York State: an 21. Thabah R, Sailo LT, Bardoloi J, Lanleila M,
bypass grafting. J Thorac Cardiovasc Surg. analysis of 10 years’ experience. Transfusion. Lyngdoh NM, Yunus M, Bhattacharyya P.
2012;143(1):178-185. [Medline] 2000;40(10):1207-1213. [Medline] ‘Maximum Surgical Blood Order Schedule’ in
7. Carson JL, Grossman BJ, Kleinman S, et al. Red 14. Novis DA, Miller KA, Howanitz PJ, et al. Audit a newly set-up tertiary care hospital. Anaesth
blood cell transfusion: a clinical practice guideline of transfusion procedures in 660 hospitals. A Pain & Intensive Care 2013;17(1):28-32
from the AABB [published ahead of print March College of American Pathologists Q-Probes

ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013 3
eDIToRIAL VIeW
can you stop this shivering, doctor?
Arshad Taqi*
*Consultant anesthesiologist, Kaul Associates, Hameed Latif Hospital, Lahore (Pakistan)
Correspondence: Dr. Arshad Taqi, Consultant anesthesiologist, Kaul Associates, Hameed Latif Hospital, Lahore (Pakistan);
E-mail: [email protected]
SUMMARY
Postoperative shivering and feeling of cold associated with it is rated as worse than pain by some patients. It has
been a problem not only after general anesthesia, but also during and after spinal anesthesia. This editorial com-
pliments an original article in this issue of ‘Anesthesia, Pain & Intensive Care’ on comparison of three different
drugs for the treatment of postoperative shivering, and draws attention towards pathogenesis of shivering and
its control. Shivering is not a point in time event and its cessation with pharmacological intervention does not
guarantee against its recurrence.
Key words: Postoperative shivering; Spinal anesthesia; Tramadol; Butorphanol; Ondanstron
Citation: Taqi A. Can you stop this shivering, doctor? Anaesth Pain & Intensive Care 2013;17(1):4-5
Shivering evolved as a protective response against Monoamine theory of thermoregulation proposed by
hypothermia in mammals. This blessing may turn out Feldberg and Meyers in 1963 attributed maintenance of
to be a cause for distress in a significant number of body temperature to a balance between norepinephrine
patients undergoing anesthesia. Postoperative shivering and 5-hydoxytryptamine (5-HT) in preoptic area
is accompanied by cutaneous vasoconstriction and of anterior hypothalamus. We now know that
occurs in response to intraoperative hypothermia in temperature regulation is not confined to a specific
majority of cases. Shivering associated with pain and area of the brain, it is rather modulated by an interplay
accompanied by cutaneous vasodilatation is observed between different areas of the brain and spinal cord and
in around 15% cases.1 Hypothermia during central chemical mediation is not confined to norepinephrine
neuraxial blocks is thought to be a consequence of and 5-HT, peptides and cholinergic receptors influence
absence of sensory input from the lower limbs. the interthreshold range (range of temperatures between
Patients rate shivering as highly uncomfortable; onset of shivering and sweating).7 Therapies aimed at
feeling of cold associated with shivering is rated as control of shivering largely work by targeting these
worse than pain by some patients. It increases oxygen chemical mediators. Tramadol largely works through
consumption, increases intraocular and intracranial its effect on alpha-2 receptors; nefopam, is a powerful
pressures, interferes with monitoring and adds antishivering agent inhibiting synaptosomal uptake
to postoperative pain by stretching the wounds2. of serotonin (5-HT), norepinephrine and dopamine.
Postoperative pain on the other hand may facilitate NMDA receptors are also involved, which explains the
nonthermogenic shivering.3 Eberhart has shown that role of ketamine in preventing and treating shivering.8
beside patient’s age and endoprosthetic procedures,
In this issue of this journal, Suresh et al have compared
core hypothermia is an independent risk factors for
the efficacy and safety of ondansetron, butorphanol
postoperative shivering.4 Cutaneous warming improves
and tramadol for control of shivering in patients
patient comfort and reduces oxygen consumption but
undergoing surgery under spinal anesthesia.9 This
fails to decrease the duration of shivering in patients
study highlights the importance of pharmacological
undergoing both regional and general anesthesia. This
interventions in control of shivering. The study is
highlights the limited role of skin temperature in the
well designed; method of randomisation is described,
control of shivering.5 Rapid and effective control
both subjects and observers were blinded, eliminating
of shivering, therefore, is largely achieved using
the possibility of selection or observer bias; a sample
pharmacological means. A wide range of drugs have
size with the power to detect the difference between
been tried with varying results; pethidine remains the
interventions was calculated and enough patients were
most frequently tested drug with a consistent efficacy
recruited to have 13 or more patients shivering in
with an intravenous dose that is not likely to cause
each group; minimum required to detect a difference
significant side effects.6
with sufficient power. Results of the study, however
4 ANAESTH, PAIN & INTENSIVE CARE; VOL 17(1) JAN-APR 2013