title: Prevention of shivering during therapeutic temperature modulation: the Columbia anti-shivering protocol.
abstract: BACKGROUND
  As the practice of aggressive temperature control has become more commonplace, new clinical problems are arising, of which shivering is the most common. Treatment for shivering while avoiding the negative consequences of many anti-shivering therapies is often difficult. We have developed a stepwise protocol that emphasizes use of the least sedating regimen to achieve adequate shiver control.
  
  
  METHODS
  All patients treated with temperature modulating devices in the neurological intensive care unit were prospectively entered into a database. Baseline demographic information, daily temperature goals, best daily GCS, and type and cumulative dose of anti-shivering agents were recorded.
  
  
  RESULTS
  We collected 213 patients who underwent 1388 patient days of temperature modulation. Eighty-nine patients underwent hypothermia and 124 patients underwent induced normothermia. In 18% of patients and 33% of the total patient days only none-sedating baseline interventions were needed. The first agent used was most commonly dexmeditomidine at 50% of the time, followed by an opiate and increased doses of propofol. Younger patients, men, and decreased BSA were factors associated with increased number of anti-shivering interventions.
  
  
  CONCLUSIONS
  A significant proportion of patients undergoing temperature modulation can be effectively treated for shivering without over-sedation and paralysis. Patients at higher risk for needing more interventions are younger men with decreased BSA.
authors.affiliation: The Neurological Institute of New York, Columbia University College of Physicians and Surgeons, New York, NY, USA.
authors.forename: H Alex
authors.initials: HA
authors.lastname: Choi
authors.forename: Sang-Bae
authors.initials: SB
authors.lastname: Ko
authors.forename: Mary
authors.initials: M
authors.lastname: Presciutti
authors.forename: Luis
authors.initials: L
authors.lastname: Fernandez
authors.forename: Amanda M
authors.initials: AM
authors.lastname: Carpenter
authors.forename: Christine
authors.initials: C
authors.lastname: Lesch
authors.forename: Emily
authors.initials: E
authors.lastname: Gilmore
authors.forename: Rishi
authors.initials: R
authors.lastname: Malhotra
authors.forename: Stephan A
authors.initials: SA
authors.lastname: Mayer
authors.forename: Kiwon
authors.initials: K
authors.lastname: Lee
authors.forename: Jan
authors.initials: J
authors.lastname: Claassen
authors.forename: J Michael
authors.initials: JM
authors.lastname: Schmidt
authors.forename: Neeraj
authors.initials: N
authors.lastname: Badjatia
mesh_terms: D058647:Adrenergic alpha-2 Receptor Agonists / Q000008:administration & dosage*; D000328:Adult; D000368:Aged; D000927:Anticonvulsants / Q000008:administration & dosage; D016292:Procedural Sedation / Q000379:methods*; D003422:Critical Care / Q000379:methods*; D020927:Dexmedetomidine / Q000008:administration & dosage*; D004305:Dose-Response Relationship, Drug; D005260:Female; D005334:Fever / Q000628:therapy*; D015600:Glasgow Coma Scale; D006323:Heart Arrest / Q000628:therapy*; D006801:Humans; D007036:Hypothermia, Induced / Q000009:adverse effects*; D007362:Intensive Care Units; D019586:Intracranial Hypertension / Q000628:therapy*; D008278:Magnesium Sulfate / Q000008:administration & dosage; D008297:Male; D008614:Meperidine / Q000008:administration & dosage*; D008875:Middle Aged; D008991:Monitoring, Physiologic; D009294:Narcotics / Q000008:administration & dosage*; D003473:Neuromuscular Nondepolarizing Agents / Q000008:administration & dosage; D015742:Propofol / Q000008:administration & dosage*; D011446:Prospective Studies; D012768:Shivering / Q000187:drug effects*; D014673:Vecuronium Bromide / Q000008:administration & dosage
chemical_list: D058647:Adrenergic alpha-2 Receptor Agonists; D000927:Anticonvulsants; D009294:Narcotics; D003473:Neuromuscular Nondepolarizing Agents; D020927:Dexmedetomidine; D008278:Magnesium Sulfate; D014673:Vecuronium Bromide; D008614:Meperidine; D015742:Propofol