Postoperative shivering is a common and often distressing complication in surgical patients. It is caused by perioperative hypothermia, which is exacerbated by anesthetic-induced thermoregulatory impairment. The incidence of shivering varies depending on the type of surgery, anesthetic technique, and individual patient factors. Certain surgeries, particularly those involving neuraxial anesthesia or prolonged exposure, are associated with a higher incidence of postoperative shivering.
Neurosurgical procedures, especially those under total intravenous anesthesia, have demonstrated a consistently high rate of early postoperative shivering. Wong et al. conducted an audit of elective neurosurgical procedures involving total intravenous anesthesia with propofol and remifentanil and reported a significant incidence of shivering despite temperature management protocols (1). Manninen et al. corroborated these findings, reporting that early postoperative complications, including shivering, were significantly more prevalent following neurosurgical interventions due to extended surgical durations and the profound suppression of thermoregulatory mechanisms by anesthetics (2).
Spinal anesthesia is an anesthetic technique commonly associated with a higher incidence of postoperative shivering, implicating lower abdominal and lower limb surgeries, such as cesarean sections and orthopedic procedures. In a comparative study of cesarean sections, Amr et al. found that the use of combined spinal-epidural anesthesia led to shivering in over 50% of cases, even when adjuncts such as magnesium sulfate were administered to mitigate the effects. Similarly, a meta-analysis by Liu et al. reviewing cesarean sections under spinal anesthesia revealed the significant impact of adjuvants such as dexmedetomidine in reducing, though not eliminating, the incidence of shivering (3).
Thoracic surgeries, particularly those performed via video-assisted thoracoscopic surgery (VATS), also carry a relatively high risk of postoperative hypothermia and shivering. Xiao et al. demonstrated that, despite the use of preoperative forced-air warming systems, patients undergoing VATS procedures exhibited high incidences of postoperative shivering. This is likely due to the combination of prolonged operative time, low ambient operating room temperatures, and the large surface area exposed during surgery (4).
Plastic surgeries have also been identified as high-risk procedures for postoperative hypothermia and shivering. These procedures often involve extensive tissue exposure and are typically performed in cool environments to reduce bacterial contamination. Young et al. emphasized the importance of perioperative warming strategies in preventing hypothermia and its consequences, such as shivering, especially in long aesthetic procedures (5). Despite these measures, shivering remains a frequent complication due to the multifactorial nature of thermoregulatory disruption.
In conclusion, surgeries involving neuraxial anesthesia (e.g., spinal or epidural blocks), prolonged exposure, and substantial tissue manipulation, such as neurosurgical, thoracic, obstetric, and plastic surgeries, demonstrate the highest incidence of postoperative shivering. Although prophylactic pharmacologic strategies and active warming techniques have been implemented with varying degrees of success, none have completely eliminated this complication. Recognizing high-risk procedures enables anesthesiologists and surgical teams to proactively implement targeted strategies to prevent shivering, thereby improving patient comfort and recovery outcomes.
References
- Wong AY, O’Regan AM, Irwin MG. Total intravenous anaesthesia with propofol and remifentanil for elective neurosurgical procedures: an audit of early postoperative complications. Eur J Anaesthesiol. 2006;23(7):586-590. doi:10.1017/S0265021506000214
- Manninen PH, Raman SK, Boyle K, el-Beheiry H. Early postoperative complications following neurosurgical procedures. Can J Anaesth. 1999;46(1):7-14. doi:10.1007/BF03012507
- Liu X, Zhang X, Wang X, Wang J, Wang H. Comparative evaluation of intrathecal bupivacaine alone and bupivacaine combined with dexmedetomidine in cesarean section using spinal anesthesia: a meta-analysis. J Int Med Res. 2019;47(7):2785-2799. doi:10.1177/0300060518797000
- Xiao Y, Zhang R, Lv N, Hou C, Ren C, Xu H. Effects of a preoperative forced-air warming system for patients undergoing video-assisted thoracic surgery: A randomized controlled trial. Medicine (Baltimore). 2020;99(48):e23424. doi:10.1097/MD.0000000000023424
- Young VL, Watson ME. Prevention of perioperative hypothermia in plastic surgery. Aesthet Surg J. 2006;26(5):551-571. doi:10.1016/j.asj.2006.08.009