What is the treatment plan for a patient with shivering and no fever?

Treatment Plan for Shivering Without Fever

For patients with shivering without fever, the first-line treatment approach should include non-pharmacological interventions such as surface counterwarming, followed by pharmacological options including acetaminophen, magnesium sulfate, and meperidine if needed, with careful escalation to sedatives only when necessary. 1, 2

Causes of Shivering Without Fever

• Thermoregulatory response to hypothermia is the most common cause, triggered when core temperatures fall below a set threshold (usually 35.5–36°C) 2
• Medication reduction or withdrawal, particularly when sedative medications that were previously suppressing shivering are decreased 2
• Inadequate warming during or after procedures 2, 3
• Pain can trigger non-thermoregulatory shivering even in normothermic patients 4
• Metabolic causes including electrolyte abnormalities 2

Assessment

• Differentiate shivering from seizures by observing movement pattern (shivering presents as rhythmic, oscillatory movements that are typically bilateral and symmetric) 5
• Check core temperature to determine if hypothermia is the cause 5, 3
• Assess for other potential causes including pain, medication withdrawal, or infection 2, 4
• Document the severity of shivering using a standardized scale to guide treatment decisions 6

Treatment Algorithm

Step 1: Non-pharmacological Interventions

• Implement surface counterwarming techniques, particularly focusing on warming extremities, ears, palms, and soles 1
• Use forced-air warming systems if available 5, 3
• Ensure adequate room temperature 3
• Address any underlying pain with appropriate analgesia 4

Step 2: First-line Pharmacological Interventions

• Administer acetaminophen as an antipyretic that can help reduce the shivering threshold 1
• Consider magnesium sulfate (2-4 g bolus, followed by 1 g/h if needed) as a non-sedating adjunct 1
• Add buspirone 30 mg every 8 hours if shivering persists 1, 6
• Consider ondansetron 4-8 mg every 4-8 hours as an additional non-sedating option 1

Step 3: Second-line Pharmacological Interventions

• If shivering persists, meperidine 12.5-50 mg is the most effective anti-shivering agent 1, 7
• For patients with contraindications to meperidine, consider low-dose fentanyl bolus with infusion as an alternative analgesic approach 1

Step 4: Escalation to Sedatives (if necessary)

• Add dexmedetomidine infusion if shivering continues despite above measures 1, 8
• Consider propofol (0.5-1 mg/kg bolus, 20-60 μg/kg/min infusion) as an alternative sedative 1
• Avoid benzodiazepines if possible due to risk of delirium and prolonged sedation 1

Step 5: Last Resort (for refractory shivering)

• Neuromuscular blocking agents may be considered for refractory cases, but only after ensuring adequate sedation 1, 7
• Cisatracurium (0.1-0.2 mg/kg) is preferred in patients with renal or hepatic impairment 1
• Monitor train-of-four responses to titrate to minimum effective dose 1

Special Considerations

• Younger patients, men, and those with decreased body surface area may require more aggressive anti-shivering interventions 8
• In patients with cardiovascular compromise, use caution with sedatives that may cause hemodynamic instability, particularly propofol and dexmedetomidine 1
• For patients with traumatic brain injury, carefully assess the risk-benefit ratio of strict temperature control versus permissive hyperthermia 1
• Shivering can significantly increase metabolic rate and oxygen consumption, which may be detrimental in patients with limited cardiopulmonary reserve 2

Common Pitfalls to Avoid

• Overuse of sedatives and neuromuscular blockers before trying non-pharmacological and non-sedating pharmacological options 6
• Failure to recognize that shivering may be masking seizures in neurologically injured patients 5
• Inadequate monitoring for side effects of anti-shivering medications, particularly respiratory depression with opioids 1, 7
• Not addressing the underlying cause of shivering (e.g., hypothermia, pain) 3, 4