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Nefopam and Tramadol for the Prevention of Shivering During Neuraxial Anesthesia
  1. Federico Bilotta, M.D., Ph.D.,
  2. Paolo Pietropaoli, M.D.,
  3. Raffaele Sanitá, M.D.,
  4. Gianni Liberatori, M.D. and
  5. Giovanni Rosa, M.D.
  1. From the Department of Anesthesia and Intensive Care, University of Rome “La Sapienza” (F.B., P.P., G.R.), Rome; and the Department of Anesthesia Policlinico Casilino (R.S., G.L.), Rome, Italy.
  1. Reprint requests: Federico Bilotta, M.D., Ph.D., via dei Tadolini 13, Rome 00196, Italy. E-mail: bilotta{at}


Background and Objectives In patients undergoing neuraxial anesthesia, heat loss and core-to-peripheral redistribution of body heat causes the core temperature to decrease. The shivering threshold is therefore reached soon, and more shivering is required to prevent further hypothermia. Because shivering has deleterious metabolic and cardiovascular effects, it should ideally be prevented by pharmacologic or other means. We evaluated the usefulness of intravenous (IV) nefopam and tramadol in preventing and reducing the severity of shivering in patients undergoing neuraxial anesthesia for orthopedic surgery.

Methods Ninety patients, scheduled for neuraxial anesthesia (epidural or subarachnoid) for lower limb orthopedic surgery, were prospectively enrolled. Patients were randomly assigned to 1 of 3 groups. Immediately before neuraxial anesthesia, 30 patients received 0.15 mg/kg−1 IV nefopam in 10 mL saline, 30 patients received 0.5 mg/kg−1 IV tramadol in 10 mL saline, and a control group of 30 patients received 10 mL IV saline. Neuraxial anesthesia was induced at the L3-L4 or L4-L5 interspaces with 1 mg/kg−1 mepivacaine for epidural anesthesia and 0.2 mg/kg−1 for subarachnoid anesthesia. An investigator blinded to the antishivering drug injected recorded the frequency and degree of shivering.

Results The overall frequency and the intensity of shivering was significantly lower in patients treated with nefopam than in those treated with tramadol or placebo (P < .05 and P < .01) and in patients treated with tramadol than in those treated with placebo (P < .05).

Conclusions As a pharmacologic means of preventing shivering in patients undergoing neuraxial anesthesia, nefopam may hold the greatest promise.

  • Anesthetic techniques
  • Epidural and subarachnoid
  • Complications
  • Shivering
  • Pharmacology
  • Nefopam
  • Tramadol

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  • Supported in part with departmental research funds, without a corporate sponsor.

    Presented in part at the 9th Annual Meeting of the European Society of Anaesthesiologists, Gothenburg, Sweden, April 7-10, 2001.

    None of the authors have a financial association with the manufacturer of nefopam or tramadol.