What is the role of hydrocortisone (corticosteroid) in treating shivering?

Hydrocortisone for Shivering

Hydrocortisone at doses of 1-2 mg/kg IV is effective in preventing and treating postoperative shivering, with a significant reduction in both incidence and severity compared to placebo. 1

Mechanism and Evidence

• Hydrocortisone has been shown to reduce postoperative shivering in patients undergoing surgery under general anesthesia, with effectiveness demonstrated at both 1 mg/kg and 2 mg/kg IV doses 1
• A systematic review and meta-analysis of randomized controlled trials found that prophylactic corticosteroids (including hydrocortisone) significantly reduced the risk of overall shivering (RR 0.65) and moderate to severe shivering (RR 0.49) compared to controls 2
• Specifically for hydrocortisone, the risk reduction for shivering was substantial (RR 0.51) when administered intravenously 2

Clinical Applications

For Postoperative Shivering

• Administer hydrocortisone 1-2 mg/kg IV approximately 10 minutes before the end of anesthesia for prophylaxis 1
• Both 1 mg/kg and 2 mg/kg doses show similar efficacy in preventing shivering, with no significant difference between these dosages 1

For Shivering During Targeted Temperature Management

• In patients with severe traumatic brain injury undergoing targeted temperature control, shivering assessment and management is critical 3
• When shivering is detected and ICP is labile, ensure appropriate depth of sedation first, then consider neuromuscular blockers if needed 3
• Hydrocortisone can be considered as part of the pharmacological approach to control shivering, alongside other agents 4

For Septic Shock with Shivering

• In patients with septic shock who remain hypotensive despite fluid resuscitation and vasopressor therapy, hydrocortisone may be administered at a dose of 200 mg/day 3
• While primarily used for hemodynamic stabilization in septic shock, hydrocortisone may provide the additional benefit of reducing shivering 3
• Hydrocortisone may be administered as an intermittent or continuous infusion at dosages ranging from 1-2 mg/kg/day for stress coverage to 50 mg/kg/day titrated to reversal of shock 3

Important Considerations

• Hydrocortisone should not be routinely used for shivering in patients with sepsis in the absence of shock 3
• In patients with liver failure and septic shock in the ICU, hydrocortisone has been associated with a higher rate of shock recovery but also with increased risk of gastrointestinal bleeding 3
• For patients undergoing targeted temperature management, a stepwise approach to shivering control is recommended, starting with non-pharmacologic methods and acetaminophen, buspirone, and magnesium sulfate before considering other agents 4

Potential Side Effects and Monitoring

• When using hydrocortisone for shivering, monitor for potential adverse effects including hyperglycemia, which occurs in up to 90.9% of patients receiving hydrocortisone 5
• Other potential adverse effects include increased risk of secondary infections, muscle weakness, and impaired wound healing 5
• In patients with septic shock, hydrocortisone may hasten reversal of shock but has been associated with episodes of superinfection, including new sepsis and septic shock 6

Conclusion

Hydrocortisone is an effective option for managing shivering, particularly in the postoperative setting at doses of 1-2 mg/kg IV. While it can also be considered for shivering during targeted temperature management or in septic shock, its use should be balanced against potential adverse effects and integrated into a comprehensive approach to patient management.