What is the best course of action for a cancer patient experiencing acute shivering during a therapeutic ascitic (abdominal fluid removal) tap?

Management of Acute Shivering During Therapeutic Paracentesis in Cancer Patients

Immediately stop or slow the drainage, apply external warming with heated blankets or forced-air warming devices, and administer intravenous meperidine 12.5-50 mg as the most effective pharmacological intervention for acute shivering. 1

Immediate Actions

Stop or Modify the Procedure

• Pause or significantly slow the rate of ascitic fluid drainage to prevent further rapid fluid shifts and temperature changes that trigger shivering 1
• Rapid drainage of large volumes of peritoneal fluid can cause hemodynamic instability and temperature dysregulation, which are primary triggers for shivering in this setting 2

Non-Pharmacological Interventions (First-Line)

• Apply surface counterwarming immediately using forced-air warming devices or heated blankets, as these are the most validated non-pharmacological methods for shivering control 1
• Ensure the patient is covered with warm blankets and the room temperature is increased 3
• Administer warmed intravenous saline (100 ml/kg subcutaneously in multiple sites if signs of shock develop) and place the patient on a heating pad 1

Pharmacological Management

Meperidine as First-Line Agent

• Meperidine 12.5-50 mg IV is the most potent anti-shivering medication with a duration of action of 2-4 hours 1
• This opioid has unique anti-shivering properties superior to other analgesics, making it the preferred agent when pharmacological intervention is needed 1
• Important caveat: Meperidine has an active metabolite associated with neurotoxicity and decreases seizure threshold, so use cautiously in patients with renal impairment or seizure history 1

Alternative Pharmacological Options

• Low-dose fentanyl (25-100 μg bolus) can be used if meperidine is contraindicated, though it has less potent anti-shivering effects 1
• Acetaminophen can be considered as an adjunct, particularly if there is concern about infection-related fever 1
• Magnesium sulfate (2-4 g IV) may provide additional anti-shivering benefit when combined with other agents 1

Monitoring During and After Intervention

Assess for Complications

• Monitor for signs of shock including tachypnea, hunched posture, pale mucous membranes, and inactivity for at least 30 minutes after the shivering episode 1
• If signs of shock persist >30 minutes despite warming and fluid resuscitation, this represents a serious complication requiring immediate medical intervention 1
• Check vital signs frequently as hypotension occurs in approximately 0.6% of paracentesis procedures and can be exacerbated by rapid drainage 4, 5

Resume Drainage Cautiously

• Once shivering is controlled and the patient is stable, drainage may be resumed at a slower rate (typically over 1-4 hours for complete drainage rather than rapid removal) 6
• The European Association for the Study of the Liver recommends draining ascites to dryness in a single session, but this should be done gradually to avoid complications 6

Prevention for Future Procedures

Pre-Procedure Warming

• Initiate active warming before beginning paracentesis in patients at high risk for shivering (those with previous episodes, cachexia, or large-volume ascites) 1, 3
• Consider prophylactic low-dose meperidine or fentanyl before starting drainage in patients with prior shivering episodes 1

Optimize Drainage Technique

• Control drainage rate to prevent rapid fluid shifts—avoid removing >5 liters in the first hour 6, 2
• For volumes >5 liters, ensure albumin replacement (8 g per liter removed) is administered to prevent post-paracentesis circulatory dysfunction, which can contribute to temperature dysregulation 6

Critical Pitfalls to Avoid

• Do not ignore shivering as a benign symptom—it can indicate hemodynamic instability, hypothermia, or rapid fluid shifts that may lead to serious complications including hypotension and circulatory collapse 2, 5
• Do not continue rapid drainage once shivering begins, as this increases oxygen consumption by up to 400% and can precipitate lactic acidosis and cardiovascular stress in already compromised cancer patients 3
• Avoid using sedatives alone (propofol, midazolam) without addressing the underlying cause, as these have weaker anti-shivering properties and higher risk of hypotension compared to meperidine 1
• Do not assume infection is the cause without evidence—shivering during paracentesis is more commonly related to rapid fluid shifts, hypothermia, and pain rather than spontaneous bacterial peritonitis, which would present with fever and other systemic signs 7, 3