Shivering Research Articles

ORAL MISOPROSTOL VERSUS INTRAMUSCULAR OXYTOCIN IN THE ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOUR

Background: The third stage of labor is defined as the time between the delivery of the baby and delivery of the placenta. The third stage of labor is potentially the most dangerous part for the mother. The main risk is the occurrence of postpartum hemorrhage. Objective: To compare the efficacy and safety of oral misoprostol with intramuscular oxytocin in the active management of third stage of labor for the prevention of postpartum hemorrhage. Patient and Methods: The study was conducted in the labor ward of Obstetrics and Gynecology Department at Imbaba General Hospital from September 2018 till September 2019. This study included four hundred healthy pregnant women during the course of normal labor. Patients in this study were randomly divided into two equal groups: Group (I) received 600 mcg Misoprostol orally within 1 minute of delivery of the baby and Group (II) received 10 IU oxytocin intramuscularly within 1 minute of delivery of the baby. We compared the two groups using computer programs to evaluate the safety and efficacy of each drug. The primary outcome measure was postpartum fall in haemoglobin after 8 h of delivery. Secondary outcome measure was duration of third stage of labor, need for an additional uterotonic drug, need for blood transfusion and side effects of both the drugs. Results: There was no significant difference between the two groups regarding the duration of the third stage of labor, the change in hemoglobin and hematocrit levels from before labor to 8 hours postpartum, and the occurrence of complications (the need for more utrotonic drugs and the need for blood transfusion). As regard the duration of third stage of labor, there was a slight advantage for the oxytocin group over the misoprostol group, 4% of cases in oxytocin group have side effects, while 13% of cases in misoprostol group have sides effects in the form of nausea, vomiting, fever, shivering. Conclusions: No major difference in oral misoprostol and intramuscular oxytocin in the management of third stage of labor.

Exploration of the relationship between puerperal shivering and amniotic fluid entering into the blood during cesarean section

Objective To investigate the relationship between shivering and amniotic fluid entering into the blood during cesarean section, and provide new thoughts for prevention and treatment of shivering during cesarean section. Methods This was a prospective, double-blinded, and controlled study. A total of 57 puerperants [American Society of Anesthesiologists (ASA)ⅠorⅡ] received subarachnoid block, whose shivering were observed and classified by chief anesthesiologists. Their general information (name, age, height and weight), blood loss, fluid intake, gestational age, neonatal weight, the length of operation, neonatal 1 minute Apgar score and shivering grade were recorded. Their anal temperatures before anesthesia, 30 min after anesthesia and at the end of the operation were measured and recorded. The puerperants were divided into four groups according to Dewitte shivering classification: grade 0 is a non-shivering group (group 0); shivering grades 1 to 3 were divided into groups 1, 2 and 3, respectively, where groups 1 to 3 were defined as shivering groups. Then, 2 ml of venous blood were taken from all the puerperants before the end of the operation to detect the concentration of sialyl Tn (sTn) antigen. The correlations between shivering degree and sTn antigen concentrations, gestational age, blood loss, fluid intake, the length of operation, neonatal weight and anal temperature at three time points were analyzed. Results There was no significant difference in age, height, weight, blood loss, fluid intake, gestational age, neonatal weight, the length of operation, and anal temperature at three time points among these groups (P>0.05). Compared to groups 0 and 1, groups 2 and 3 produced higher concentrations of sTn antigen (P<0.05), while the concentration of sTn antigen in group 1 was higher than that in group 0 (P< 0.05). The concentrations of sTn antigen in the shivering groups were significantly higher than that in the non-shivering group (P<0.05). The correlation coefficient between shivering degree and sTn antigen concentration was 0.895 (P<0.01). There was no correlation between shivering degree and gestational age, blood loss, fluid intake, the length of operation, neonatal weight and anal temperature at three time points. Conclusions Puerperant shivering is related with amniotic fluid entering into the blood during cesarean section. Key words: Cesarean section; Shivering; Amniotic fluid; Sialyl Tn antigen

Thieves of Weirdwood by William Shivering

Thieves of Weirdwood by William Shivering

Pharmacological Approach for the Prevention of Postoperative Shivering: A Systematic Review of Prospective Randomized Controlled Trials

Shivering is a common postoperative complication that occurs after both general and regional anesthesia even in the cases when hypothermia during surgery has been averted. Patients describe it as a highly unpleasant experience, while clinicians are concerned due to its adverse effects such as increased oxygen consumption. In this article, we present a summary of the pathophysiological mechanisms involved in postoperative shivering (POS), risk factors, and inadvertent effects. The major objective of this article was to review the existing literature on the effi ciency of various drug interventions as a prophylactic measure against POS. Since α2-adrenergic, opioid, anticholinergic, and serotonergic pathways are thought to play a role in the pathogenesis of POS, a wide variety of drugs has been investigated in this regard. Although the methodological diversity of the study designs and regimens does not support drawing defi nite conclusions, there is evidence indicating a benefi cial effect of dexmedetomidine, ketamine, tramadol, meperidine, dexamethasone, nefopam, granisetron, and ondansetron in the prevention of POS. The purpose of this review is to provide a thorough insight on various drug options and to serve as an aid for clinicians for careful analysis of the advantages and disadvantages of each regimen to decide which regimen will be ideally suited for the medical profi le of each patient.

Hypothermia Following Spinal Anesthesia in an Infant: Potential Impact of Intravenous Dexmedetomidine and Intrathecal Clonidine

The ? 2 -adrenergic agonists (dexmedetomidine and clonidine) have been used in several different clinical scenarios in infants and children including sedation during mechanical ventilation, procedural sedation, supplementation of postoperative analgesia, prevention of emergence delirium, control of post-anesthesia shivering, treatment of withdrawal and prolonging of duration of neuraxial anesthesia. Hemodynamic effects including bradycardia and hypotension remain the predominant adverse effects reported with the ? 2 -adrenergic agonists. We report hypothermia following intravenous sedation with dexmedetomidine and spinal anesthesia with a combination of bupivacaine and clonidine in a 2-month-old infant. The potential mechanisms involved are reviewed, the causal relationship between hypothermia and ? 2 -adrenergic agonists is explored and interventions to avoid its development are presented. J Med Cases. 2019;10(11):319-322 doi: https://doi.org/10.14740/jmc3391

Comparison of efficacy of active forced-air warming for preventing perioperative hypothermia between the elderly and young patients

Objective To observe whether the active forced-air warming has the same efficacy on the prevention of perioperative hypothermia in the elderly as compared with young patients. Methods This was a prospective, randomized, controlled clinical trial.Forty patients scheduled for abdominal surgery under general anesthesia were allocated to two groups: the elderly group and the young group(n=20, each). All patients received active forced-air warming at 20-30 min before induction of anaesthesia till leaving the operation room.Blood products and peritoneal lavage fluids were warmed to 37℃, and other intravenous fluids were at room-temperature.The core temperatures were recorded after entering the operation room(baseline), before induction of anaesthesia, at 15 min intervals after induction of anaesthesia, at the end of surgery and before leaving the operation room.The postoperative shivering and adverse reactions were also recorded. Results The core temperature was lower in elderly patients than in young patients at baseline and at each time points after 30 min of induction of anaesthesia(P<0.05). In elderly patients, the core temperature was significantly lower before leaving operation room than at the baseline(t=2.353, P=0.03), but in young patients, no significant difference was found in the core temperature between at the baseline and before leaving operation room(t=0.233, P=0.818). The incidence of intra-operative hypothermia was higher in elderly patients than in young patients(40.0% or 8/20 vs.5.0% or 1/20, c2=7.025, P=0.008). Conclusions During abdominal surgery under general anesthesia, active forced-air warming cannot effectively prevent perioperative hypothermia in elderly patients as compared with young patients. Key words: Anesthesia, general; Body temperature regulation

Effect of intraoperative warming on delirium during emergence from general anesthesia in elderly patients

Objective To evaluate the effect of intraoperative warming on delirium during emergence from general anesthesia in elderly patients. Methods Eighty elderly patients of both sexes, aged≥65 yr, of American Society of Anesthesiologists physical statusⅠ-Ⅲ, scheduled for elective total hip replacement, were assigned to routine group (group R, n=40) and warming group (group W, n=40). The non-operated site was covered using the sterile cloth, and no other active warming measurements were given in group C. Fluid was infused and warmed to 37 ℃, the non-operated site was covered using the forced-air warming system, and the temperature of the forced-air warming system was maintained at 38-42 ℃ in group W. The tympanic membrane temperatures was recorded at 5 min after anesthesia induction, at 30, 60 and 90 min after beginning of surgery, at the end of surgery and at 30 min after emergence from anesthesia, and the difference between monitored values and monitored values on admission to operating room (△T) was recorded at each time point. The intraoperative volume of fluid infused, operation time, extubation time, duration of postanesthesia care unit stay and development of delirium during emergence and shivering were recorded. Results Compared with group R, △T was significantly decreased at 60 and 90 min after beginning of surgery, the incidence of delirium during emergence and shivering was decreased, the extubation time and duration of postanesthesia care unit stay were shortened in group W (P<0.05). Conclusion Intraoperative warming can decrease the development of delirium during emergence from general anesthesia and is helpful in improving the quality of recovery from anesthesia in elderly patients. Key words: Body temperature; Aged; Anesthesia recovery period; Delirium

Optimum compatibility of nabufine mixed with flurbiprofen for patient-controlled intravenous analgesia after gynecological laparoscopic surgery: a multicenter, randomized, controlled clinical trial

Objective To evaluate the optimum compatibility of nabufine mixed with flurbiprofen for patient-controlled intravenous analgesia (PCIA) after gynecological laparoscopic surgery. Methods A total of 210 patients, aged 18-64 yr, with body mass index of 18-30 kg/m2, of American Society of Anesthesiologist physical status Ⅰor Ⅱ, scheduled for gynecological laparoscopic surgery under general anesthesia, were divided into 4 groups using a random number table method: sufentanil 2.0 μg/kg+ flurbiprofen axetil 2.0 mg/kg group (SF group, n=55), nalbuphine 1.5 mg/kg+ flurbiprofen axetil 2.0 mg/kg group (N1F group, n=49), nalbuphine 2.0 mg/kg+ flurbiprofen axetil 2.0 mg/kg group(N2F group, n=55) and nalbuphine 3.0 mg/kg + flurbiprofen axetil 2.0 mg/kg group (N3F group, n=51). PCIA solution was prepared correspondingly after surgery in each group. The PCA pump was set up to deliver a 1 ml bolus dose with a 15-min lockout interval and background infusion at 2.0 ml/h. Nalbuphine 5 mg or sufentanil 5 μg was intravenously injected as a rescue analgesic to maintain visual analogue scale score at rest <4 at 48 h after surgery in SF and N1F-N3F groups. Ramsay sedation scores were recorded on admission to post-anesthesia care unit (T1), at the time of post-anesthesia care unit discharge (T2) and at 6, 24 and 48 h after surgery (T3-5). The total pressing times of PCIA in 0-6 h, 6-24 h and 24-48 h periods after surgery and requirement for rescue analgesics were recorded. The incidence of adverse reactions such as nausea and vomiting, drowsiness and shivering within 48 h after surgery was also recorded. Results Compared with group SF, the incidence of nausea and vomiting was significantly decreased in N1F and N2F groups, the requirement for rescue analgesics was significantly decreased, and the total pressing times of PCIA was reduced in N2F and N3F groups, and Ramsay sedation scores at T3, 4 were significantly increased in group N3F (P 0.05). Conclusion Nabufine 2.0 mg/kg mixed with flurbiprofen 2.0 mg/kg is the optimum compatibility when used for PCIA after gynecological laparoscopic surgery. Key words: Nalbuphine; Flurbiprofen; Analgesia, patient-controlled; Laparoscopy

Effects of bupivacaine combined with sufentanil citrate or dexmedetomidine on spinal anesthesia in transurethral resection of the prostate

Objective To evaluate the effects of bupivacaine combined with sufentanil citrate or dexmedetomidine on spinal anesthesia in transurethral resection of the prostate. Methods A total of ninety American Society of Anesthesiologists(ASA) Ⅰ or Ⅱ patients aging 65-75 y and body mass index(BMI) 20-30 kg/m2 who were scheduled for transurethral resection of prostate (TURP) were randomly divided into three groups (n=30): a dexmedetomidine group (group D), a sufentanil group (group S), and a normal saline group (group N). After spinal anesthesia with bupivacaine, dexmedetomidine (5 μg) was intrathecally injected in group D, sufentanil (5 μg) was intrathecally injected in group S, and group N received the same volume of normal saline. The blockage onset time and duration were recorded. The Richmond Agitation Sedation Scale (RASS) scores, shivering, nausea, vomiting and other adverse effects during and after operation were also recorded. Results There were no significant differences in age, BMI, operation time, transfusion volume, blood loss, and RASS scores among the three groups (P>0.05). Group S demonstrated remarkably high incidences of nausea and vomiting, compared with group N and D (P<0.05). Compared with group N, groups S and D presented remarkably decreases in the sensory blockage onset time, and increases in the blockage duration (P<0.05), and markedly reduced motion blockage onset time and extended duration(P<0.05). Conclusions Spinal anesthesia of bupivacaine combined with sufentanil or dexmedetomidine can produce good effects on TURP patients. However, patients compound dexmedetomidine got less side effects like shivering, nausea and vomiting. Key words: Dexmedetomidine; Transurethral resection of prostate; Sufentanil citrate; Bupivacaine; Subarachnoid blockage

Preoperative carbohydrate loading on perioperative temperature in patients undergoing general anesthesia

Objective The aim of this study is to investigate the effect of preoperative carbohydrate loading (CHO) on perioperative body temperature of gynaecological patients with general anesthesia. Methods Sixty female patients undergoing surgery were randomized to either fasting overnight (FAST group) or receive 800 ml of CHO in the evening before and 400 ml of CHO 2 h before anesthesia (CHO group)(n=30). Perioperative body temperatures (induction of anesthesia, after anesthesia 15, 30, 45, 60 min and the end of surgery) and degree of shivering were recorded. Results The basal temperature was not significantly different between two groups(P>0.05). The FAST group showed a significantly greater decrease in temperature from the baseline than the CHO group(P<0.05). Postoperative shivering scores of patients in FAST group is significantly higher than scores of patients in CHO group(P<0.05). Conclusions Preoperative carbohydrate loading reduces hypothermia in gynaecological patients under general anesthesia. Key words: Carbohydrate; Pretreatment; Perioperative; Hypothermia; Shivering

Effects of prospective rewarming nursing on spontaneous hypothermia in traumatic patients in emergency service

Objective To explore the effects of prospective rewarming nursing on spontaneous hypothermia in traumatic patients in emergency service. Methods Totally 67 traumatic patients admitted in the Emergency Department of Armed Police Zhejiang Corps Jiaxing Hospital between January and August 2016 were selected as the control group, and another 72 traumatic patients admitted between January and August 2017 were selected as the observation group by purposive sampling. Patients in the control group received conventional emergency treatment, while patients in the observation group received prospective rewarming nursing care on this basis. Body temperature and the incidence of shivering, arrhythmia and spontaneous hypothermia were compared between the two groups. Results The body temperature of the observation group stood at (36.38±0.21) ℃ and (36.72±0.38) ℃ respectively at admission and 1 hour post admission, both higher than that of the control group (t=24.241, 18.039; P<0.01) . The incidence rate of shivering in the observation group was 15.94% and 17.39% respectively at admission and 1 hour post admission, both lower than that of the control group (χ2=19.326, 19.141; P<0.01) . The incidence rate of arrhythmia in the observation group was 30.43%, while that of the control group was 49.15% (χ2=4.681, P=0.030) . Conclusions Prospective rewarming can reduce the risks of spontaneous hypothermia in traumatic patients in emergency service. Key words: Rewarming; Emergency service, hospital; Trauma; Spontaneous hypothermia

The effect of operating room active warming intervention on maternal hypothermia after planned cesarean

Objective To explore the effect of operating room active warming intervention on maternal hypothermia after planned cesarean. Methods According to the random number table method, from December 2016 to December 2017, 92 patients after heart failure were divided into the control group of 45 patients and the experimental group with 47 patients. Patients in the control group were conducted with the routine warming intervention, while warmed IV fluids combined with forced-air warming as active warming intervention was processed in the experimental group. The core temperature, the incidence of hypothermia, bedside shivering assessment scale, thermal comfort scores and new-born Apgar score between the two groups of patients were compared. Results Compared with the control group, the field of core temperature were significantly higher than those in the control group (F=5.96, P 0.05). Conclusion Operating room active warming intervention may have a beneficial effect on maternal hypothermia after planned cesarean, but the relevant efficacy was not shown in thefield of Apgar score. Key words: Active warming intervention; Cesarean section; Maternal hypothermia

Effects of heating intravenous fluid infusion and blood transfusion based on guidelines in sever trauma patients with hypothermia

Objective To explore the effects of heating intravenous fluid infusion and blood transfusion based on guidelines in severe trauma patients with hypothermia. Methods A total of 40 severe trauma patients with hypothermia admitted from July 2014 to December 2015 were enrolled as the control group treated with routine measures to maintain the body temperature at normothermia by such as electrical heating blanket; other 40 severe casualties with hypothermia admitted from January 2016 to July 2017 were recruited as the warming up group treated with heating intravenous fluid infusion and blood transfusion by hot water bath in addition to the routine measures for keeping body temperature at normothermia. The differences in core body temperature, prothrombin time, activated partial thromboplastin time, incidence of shivering and mortality rate were compared between the two groups. Results There was statistically significant difference in core body temperature at 0.5 h, 1.0 h, 1.5 h, 3.0 h between the two groups (P<0.05). Though the prothrombin time and shivering were improved after warming up in both groups, and there were significant differences in prothrombin time at 3.0 h after warming up and the incidence of shivering between two groups(P<0.05).There was no significant difference in mean arterial pressure at all seven intervals between two groups. Conclusion The heating intravenous fluid infusion and blood transfusion had remarkable effects to prevent hypothermia, improves blood coagulation and reduced the incidence of shivering to provide more simple and convenient warming up intervention for clinical practice. Key words: Sever trauma patients; Hypothermia; Heating intravenous infusion and blood transfusion; Rewarming

Effects of music relaxation combined warm paste on reducing hypothermia, stress response and shivering in cesarean section

Objective To explore the effects of music relaxation imagination training and warm paste on hypothermia, stress response and shivering during cesarean section. Methods A total of 120 maternals who underwent cesarean section in Huai'an Maternal and Child Health-Care Center of Jiangsu Province from March 2016 to April 2017 were selected as the research objects. According to the different nursing method, the maternals were divided into observation group and control group, with 60 cases in each group. The maternals of the control group were given the conventional nursing intervention, on the basis of which the observation group was given music relaxation imagination training combined with warm paste. The axillary temperature, heart rate and the incidence of shivering of all research objects were statistically analyzed. Results The axillary temperature and heart rate in the observation group were stable during caesarean section. However, the decline of axillary temperature and the fluctuation of heart rate in the control group were obvious. The total incidence rate of shivering of the observation group was 6.67%, which was lower than that of the control group (21.67%) , and the difference was statistically significant (χ2=5.74, P=0.03) . Conclusions Music relaxation imagination training combined with warm paste can reduce hypothermia during cesarean section, and prevent stress response. In addition, it can effectively prevent intraoperative shivering and reduce the degree of shivering. Key words: Cesarean section; Shivering; Music relaxation imagination training; Warm paste

Effects of dezocine and oxycodone on remifentanil-induced hyperalgesia

Objective To evaluate the effects of dezocine and oxycodone in preventing remifentanil-induced hyperalgesia. Methods Forty-eight patients undergoing laparoscopic gynecological surgery under general anesthesia were randomly divided into three groups (16 patients in each group), respectively received treatment with dezocine (group D) or oxycodone (group O), or without treatment (group C). Fifteen minutes before the operation, patients in group D and group O were respectively injected intravenously with dezocine 0.09 mg/kg and oxycodone 0.09 mg/kg, respectively, while the equal volume of normal saline was administered in group C. Anesthesia was induced with a combination of 0.02 mg/kg midazolam, 0.3 mg/kg etomidate, 0.2 mg/kg cisatracurium, and 1 μg/kg remifentanil. Then, the patients were ventilated with laryngeal mask airway. During the operation, BIS in electroencephalography was maintained between 40 to 60 by adjusting the dosage of propofol. Remifentanil was injected at the speed of 0.2 μg·kg-1·min-1. After surgery, VAS score and Ramsay score were also calculated, and adverse effects, such as nausea, vomiting, and shivering were recorded. The thermal pain threshold was measured before and after surgery. Results Compared with the group C, the postoperative VAS scores were significantly decreased in both group D and group O (P 0.05). Conclusions Dezocine and oxycodone were both effective in preventing remifentanil-induced thermal hyperalgesia, and dezocine can cut down the incidence of shivering. Key words: Remifentanil; Hyperalgesia; Dezocine; Oxycodone

Effect of ondansetron on hypotension and bradycardia associated with spinal anesthesia during cesarean section

Objective The aim of the study was to evaluate the efficacy of ondansetron during spinal anesthesia for cesarean section in overcoming the associated nausea, vomiting, bradycardia, and hypotension. Background Ondansetron, a widely used antiemetic and serotonin antagonist, has been safely used to blunt the Bezold–Jarisch reflex, resulting in less bradycardia and hypotension in humans undergoing spinal anesthesia. Patients and methods One hundred parturients scheduled for elective cesarean section were randomly allocated into two groups. Before induction of spinal anesthesia group I (n = 50) received intravenous ondansetron 4 mg and group II (n = 50) received normal saline. Blood pressure, heart rate (HR), nausea and vomiting, shivering, vasopressor requirements, and Apgar score at 1 and 5 min were assessed. Results Decreases in systolic arterial pressure were significantly lower in group I than in group II. Patients in group I had significantly less requirement for vasopressor (P = 0.005), needed lower dose of vasopressor (P = 0.01), and had significantly lower incidences of nausea and vomiting (P = 0.03). Decreases in HR were significantly lower in group I than in group II just after spinal anesthesia (P = 0.02), at 20 min (P = 0.01), and 50 min (P = 0.02). Decreases in mean blood pressure were significantly lower in group I than in group II just after spinal anesthesia (P = 0.007). Conclusion In parturient women undergoing elective cesarean section, intravenous 4 mg ondansetron significantly decreased the hypotension, HR fluctuation, and vasopressor doses used.

Shiver my Timbers

Shiver my Timbers

Effects of two different warming patterns on body temperature changes in patients undergoing orthopedic surgery

Objective To observe the effects of two different warming patterns on body temperature changes in patients undergoing orthopedic surgery. Methods A total of 60 patients undergoing orthopedic surgery under general anesthesia were randomly divided into the observation group and the control group, with 30 cases in each group. In the observation group, the warming blanket was set at 38℃ in an intermittent warming pattern, i.e. every 1 hour heating period was followed by a 40 min interval. In the control group, the warming blanket was set at 38℃ in a continuous warming pattern. Anal temperature was continuously monitored during operation to compare the preventive effects of the two warming patterns on hypothermia. Results Anal temperature changes were recorded at 8 time points including pre-anesthesia, the beginning of operation, 30 min, 60 min, 90 min and 120 min after the beginning of operation, completion of operation (after skin closure) and recovery of consciousness. The observation group were (36.68±0.34) ℃, (36.69±0.41) ℃, (36.60±0.37) ℃, (36.54±0.40) ℃, (36.53±0.49) ℃, (36.50±0.58) ℃, (36.49±0.61) ℃, (36.53±0.52) ℃, the control group were (36.76±0.43) ℃,(36.64±0.40) ℃, (36.50±0.39) ℃, (36.45±0.41) ℃, (36.51±0.52) ℃, (36.65±0.42) ℃, (36.65±0.44) ℃,(36.69±0.44) ℃. There were no statistical differences in anal temperature at all time points between the two groups (t=-1.332~1.083, P>0.05). In addition, the comparison of post-operation shivering, skin injury, recovery time of consciousness post-anesthesia, the observation group were,16.67%(5/30) , 0(0/30) ,(10.13±6.51) min, the control group were,10.00%(3/30) ,10.00%(3/30) ,(10.07±7.49) min, there were not significantly difference between two groups(P>0.05) . However, the incidence of sweating during operation in the control group was higher than that of the observation group (χ2=4.286, P<0.05), the observation group was 0(0/30), the control group was 13.33%(4/30). Conclusions Application of warming blanket in an intermittent warming pattern showed a similar preventive effect on hypothermia as the continuous warming pattern in patients undergoing orthopedic surgery. Moreover, intermittent warming reduced the incidences of sweating and skin injury during operation, reduce health care costs. Key words: Hypothermia; Orthopedic surgery; Body temperature changes

Efficacy of different low-doses of nalmefene in preventing remifentanil-induced postoperative hyperalgesia

Objective To evaluate the efficacy of different low-doses of nalmefene in preventing remifentanil-induced postoperative hyperalgesia. Methods One hundred American Society of Anesthesiologist physical status Ⅰor Ⅱpatients, aged 20-64 yr, wih body mass index of 18-25 kg/m2, scheduled for elective gynecological laparoscopic surgery under general anesthesia, were divided into 4 groups(n=25 each)using a random number table: control group(group C)and different doses of nalmefene groups(N1, N2 and N3 groups). In N1, N2 and N3 groups, nalmefene 0.2, 0.3 and 0.5 μg/kg(diluted to 5 ml in normal saline)were intravenously injected, respectively, at 5 min before anesthesia induction, while the equal volume of normal saline was given in group C. Anesthesia was induced with midazolam 0.05 mg/kg, sufentanil 0.3 μg/kg, etomidate 0.3 mg/kg and rocuronium 0.6 mg/kg.The patients were mechanically ventilated after tracheal intubation.Anesthesia was maintained by IV infusion of remifentanil 0.3 μg·kg-1·min-1 and inhalation of 4%-6% desflurane, bispectral index value was maintained at 45-60, and muscle relaxation was maintained with intermittent IV boluses of rocuronium.After admission to postanesthesia care unit, patient-controlled analgesia(PCA)was performed, and PCA solution contained sufentanil 1 μg/ml in 100 ml of normal saline.PCA pump was programmed to deliver a 0.5 ml bolus dose with a lockout interval of 15 min and background infusion at 2 ml/h.Numeric rating scale score was maintained <4.The time for remifentanil infusion was recorded.The consumption of sufentanil was recorded in 0-1, 1-3, 3-6, 6-12 and 12-24 h periods after surgery, and the occurrence of nausea, vomiting, tachycardia, hypertension and shivering was also recorded within 24 h after surgery. Results Compared with group C, the postoperative consumption of sufentanil was significantly reduced in 0-1 h and 1-3 h periods after surgery in group N1 and in 0-1, 1-3, 3-6 and 6-12 h periods after surgery in group N2, and the incidence of postoperative nausea was significantly decreased in N1, N2 and N3 groups(P<0.05). The consumption of sufentanil in 3-6 h period after surgery was significantly lower in group N2 than in group N1(P<0.05). Conclusion The optimal dose of nalmefene is 0.3 μg/kg when used to prevent remifentanil-induced postoperative hyperalgesia. Key words: Morphinane; Piperidines; Hyperalgesia

Neonatal Tremors Caused by Vitamin D Deficiency

Two authors in the pediatrics department at Howard University in Washington, D.C. present two cases of newborn infants who had tremors or “shivers.”The