How should post‑tracheostomy shivering be evaluated and treated?

Post-Tracheostomy Shivering: Evaluation and Treatment

Post-tracheostomy shivering should be treated as postoperative shivering using pharmacological agents—specifically nefopam 10 mg IV, tramadol 1-2 mg/kg IV, or pethidine/meperidine 25-50 mg IV—while simultaneously ruling out tracheostomy-specific emergencies that can mimic or trigger shivering, including tube obstruction, displacement, and inadequate oxygenation. 1, 2

Initial Assessment: Rule Out Tracheostomy Emergencies First

Before attributing shivering to routine postoperative causes, you must exclude life-threatening tracheostomy complications that present with agitation, restlessness, or tremor-like movements:

Immediate Airway Patency Verification

• Pass a suction catheter through the tracheostomy tube to the predetermined depth—successful passage confirms patency and correct positioning within the trachea 3
• Remove any external attachments (heat-moisture exchangers, speaking valves) and the inner cannula to exclude equipment-related obstruction 4, 3
• Apply waveform capnography immediately to verify adequate gas exchange and airway patency 4, 3
• Deliver high-flow oxygen simultaneously to both the patient's face and the tracheostomy stoma using two separate oxygen sources 4, 3

Clinical Signs of Respiratory Distress (Not Simple Shivering)

Look for stridor, accessory muscle use, tracheal tug, sternal/subcostal/intercostal recession—these indicate airway obstruction requiring emergency intervention, not pharmacological shivering treatment 4

Agitation, restlessness, and confusion may represent hypoxemia from airway compromise rather than benign postoperative shivering 4

Evaluation of True Postoperative Shivering

Once tracheostomy-specific emergencies are excluded:

Thermoregulatory Assessment

• Measure core temperature—most postanesthetic shivering is normal thermoregulatory response to core hypothermia 5
• Check for inadequate humidification through the tracheostomy, which exposes lower airways to cold, dry air and may trigger shivering 6

Non-Thermoregulatory Triggers

• Assess for postoperative pain, which causes non-thermoregulatory shivering even in normothermic patients 5
• Consider acute opioid withdrawal if short-acting narcotics were used intraoperatively 1
• Evaluate for cytokine release from the surgical procedure itself 5

Pharmacological Treatment Algorithm

The most effective agents based on network meta-analysis are nefopam, tramadol, pethidine, and clonidine 2:

First-Line Options (Ranked by Speed and Efficacy)

At 1 minute post-treatment:

• Doxapram 2 mg/kg IV (fastest onset but uncertain safety profile) 2
• Tramadol 2 mg/kg IV 2
• Nefopam 10 mg IV 2

At 5 minutes post-treatment:

• Tramadol 2 mg/kg IV 2
• Nefopam 10 mg IV 2
• Clonidine 150 µg IV 2

At 10 minutes post-treatment:

• Nefopam 10 mg IV (most sustained effect) 2
• Tramadol 1 mg/kg IV 2
• Pethidine/meperidine 25 mg IV 2

Practical Recommendations

Nefopam 10-20 mg IV is the most consistently effective agent, stopping shivering in 95% of patients compared to 32% for meperidine and 40% for clonidine, while reducing oxygen consumption and energy expenditure without adverse neurological effects 7, 2

Tramadol 1-2 mg/kg IV performs well across all time points and has extensive safety data 8, 2

Pethidine/meperidine 25-50 mg IV remains effective and widely available, though less potent than nefopam 7, 2

Clonidine 75-150 µg IV shows statistical significance in all networks but has slower onset 2

Adjunctive Non-Pharmacological Measures

Combine forced-air warming devices with intravenous medications—this is the most validated method for comprehensive shivering control 1

Ensure heat-moisture exchangers with viral filters are in place on the tracheostomy to restore humidification and prevent cold-air-induced shivering 6

Critical Pitfalls to Avoid

Never assume shivering is benign without first confirming tracheostomy tube patency—tube obstruction or displacement can present with agitation and tremor-like movements that mimic shivering 4, 3

Do not use rigid devices (bougies) to test tube patency, as they create false passages if the tube is displaced 3, 6

Never delay tube removal in a deteriorating patient—if the suction catheter cannot pass or the patient worsens despite treatment, remove the tube immediately and reassess both the upper airway and stoma 6

Avoid treating "shivering" pharmacologically when signs of respiratory distress are present (stridor, retractions, desaturation)—these require airway intervention, not antishivering medications 4

Monitor for subcutaneous emphysema in the first 0-4 days post-tracheostomy, as new emphysema signals tube malposition and should not be attributed to shivering 3