Normothermia and shivering

[calivianya, BSN, RN]

Hi guys!

I had a patient within the last month who was on hypothermia protocol post arrest. He was on our normothermia arm - after 28 hours cold, we rewarm, but leave the arctic sun pads on for an additional 44 hours to promote normothermia.

The patient was rewarmed as of 2000 that night. He was 98.9 F on the monitor, and he was shivering. My team lead came by, noticed, and immediately demanded to know why I hadn't given him any Nimbex for shivering. My answer was twofold: 1. I was drowning in my other patient's room and hadn't been in there in a couple hours and didn't have time to go in there now, and 2. he was warm, and I thought the shivering medications were only supposed to be given during the actual round of hypothermia. I told her to do what she wanted but I did not have time to take care of the shivering right then.

She went ahead and ordered a paralytic per the protocol and gave it.

I can see what the logic is, now that I think about it - shivering increases metabolic activity whether the patient is actually hypothermic or normothermic. I just wanted to know if it's common practice to still give the paralytics after the hypothermia is finished.

[MunoRN, RN]

I have a feeling what you were seeing was more likely status myoclonus rather than shivering. As a general rule based on the evidence, paralytics should be used as little as possible in TH and should only be used during the cooling phase and even then only after other interventions have failed. It is possible that in attempting to keep a patient normothermic, the blanket is so cold that it induces shivering, and the heat that shivering produces becomes the only reason for using the blanket, in which case just take the blanket off or back off on the temp and the problem is solved. If all else fails and you're about to use paralytics, sedation should be given anyway along with the nimbex, and sometimes that's all it takes.

[PaSSiNGaS, MSN]

Regardless you need to remember supply and demand of oxygen. The heart takes a very large amount of the oxygen given to it that is available. This supply and demand all revolves around oxygen consumption and shivering takes up a lot of ATP and energy to generate the impulses for muscles to behave that way. You want to get that energy down and giving a paralytic like cisatricurium or whatever you end up using is definitely needed in that scenario. Patient may be normothermic but can still shiver.

[Here.I.Stand, BSN, RN]

We give prn fentanyl first (or increase the rate on the CADD if we have room to increase), then add scheduled Buspar, and prn Demerol first before even considering a paralytic. Of course increase the MgSO4 gtt if subtherapeutic (we have a protocol to draw q 6 hrs, and adjust to keep Mg++ either 3-4, or 4-5).

We frequently cool TBI pts to 37.5 degrees -- basically aggressive fever control -- and treat their shivering. Like the PPs have said, shivering increases their cells' metabolic rates and O2 needs. Is there a reason they wanted the Arctic Sun (brutal!) as opposed to scheduled Tylenol? Did the pt have abnormal LFTs?

[PaSSiNGaS, MSN]

I'm guessing that's a typo because 37.5 degrees is not cooling.

We give prn fentanyl first (or increase the rate on the CADD if we have room to increase), then add scheduled Buspar, and prn Demerol first before even considering a paralytic. Of course increase the MgSO4 gtt if subtherapeutic (we have a protocol to draw q 6 hrs, and adjust to keep Mg++ either 3-4, or 4-5).

We frequently cool TBI pts to 37.5 degrees -- basically aggressive fever control -- and treat their shivering. Like the PPs have said, shivering increases their cells' metabolic rates and O2 needs. Is there a reason they wanted the Arctic Sun (brutal!) as opposed to scheduled Tylenol? Did the pt have abnormal LFTs?