Causes of Rigors and Shivering After IV Fluids
Rigors and shivering after IV fluid administration are most commonly caused by rapid infusion of cold fluids, but can also be due to medication reactions, infections, or inflammatory responses.
Common Causes
Temperature-Related Causes
- Infusion of cold fluids that haven't been warmed to body temperature is the most frequent cause of rigors and shivering, as the hypothalamic thermoregulatory center responds to the drop in core temperature 1
- The preoptic region of the hypothalamus triggers shivering when core temperatures fall below a set threshold (usually 35.5–36°C) 1
- Rapid administration of large volumes of room-temperature fluids can temporarily lower core body temperature enough to trigger this response 1
Medication-Related Causes
- IV iron preparations (such as iron sucrose) commonly cause rigors, chills, and shivering as infusion reactions 1, 2, 3
- High-dose IL-2 therapy frequently causes rigors and shivering within 1-2 hours of administration 1
- Some antibiotics can trigger shivering as part of an infusion reaction 1
Infection-Related Causes
- Contaminated IV fluids or IV line infections can cause rigors and shivering as part of a systemic inflammatory response 1
- Neutropenic fever protocols should be initiated for all fevers in appropriate clinical contexts, as rigors may be the first sign of infection 1
- Sepsis can present with rigors and should be considered, especially in patients with persistent hypotension unresponsive to IV fluids 1
Physiological Impact
- Shivering significantly increases metabolic demands, doubling metabolic rate and nearly tripling oxygen consumption 1
- This elevated metabolic expenditure can trigger bioenergetic failure with demand cerebral ischemia in vulnerable patients 1
- The metabolic toll of shivering is particularly concerning in patients with cardiac, respiratory, or neurological compromise 1
Management Approaches
Prevention
- Warm IV fluids to body temperature before administration, especially when large volumes are needed 1
- Consider slower infusion rates for temperature-sensitive patients 1
- For patients receiving medications known to cause rigors (like IL-2 or iron preparations), prophylactic treatment may be appropriate 1
Treatment
For mild to moderate rigors related to IV fluids or medications:
For severe rigors or those associated with hemodynamic changes:
- Stop the infusion immediately 1
- Maintain IV access with hydration fluids 1, 2
- Consider parenteral opioids such as meperidine or hydromorphone per institutional protocols for severe rigors 1
- Avoid first-generation antihistamines (like diphenhydramine) as they may convert minor infusion reactions into hemodynamically significant events 1
For rigors associated with suspected infection:
Special Considerations
- Patients with history of rigors with previous IV therapy should have fluids warmed prophylactically 1
- In post-cardiac arrest patients, shivering may be less pronounced due to hypothalamic injury, making temperature monitoring even more important 1
- Patients receiving multiple medications should be monitored closely as drug interactions may increase risk of rigors 3
- Rigors accompanied by hypotension, tachycardia, or respiratory distress require immediate medical attention as they may indicate a severe reaction 1
Monitoring Recommendations
- Monitor vital signs before, during, and after IV fluid administration 1, 2
- Pay particular attention to temperature trends, heart rate, blood pressure, and oxygen saturation 1
- For patients receiving medications known to cause rigors, implement more frequent monitoring protocols 1
- Document the timing, severity, and associated symptoms of rigors to help identify patterns and causes 1