Buspirone and Meperidine Synergistically Reduce the Shivering Threshold

Mokhtarani, Masoud; Mahgoub, Adel N.; Morioka, Nobutada; Doufas, Anthony G.; Dae, Michael W.; Shaughnessy, Thomas E.; Bjorksten, Andrew R.; Sessler, Daniel I.

doi:10.1097/00000539-200111000-00038

Cited by 162 publications

(118 citation statements)

References 36 publications

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“…Oral buspirone (30 mg) and intravenous meperidine (0.4 µg/mL) have been shown to act synergistically to lower the shivering threshold from 35.7°C to 33.4°C while producing only minimal sedation (Mokhtarani et al, 2001;Doufas et al, 2004). When skin-surface warming is used in conjunction with meperidine, the shivering threshold is additively reduced (Kimberger et al, 2007).…”

Section: Part Ii: Neuroprotection --Moving From the Present Into The mentioning

confidence: 99%

Neuroprotection for ischemic stroke: Past, present and future

2008

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Neuroprotection for ischemic stroke refers to strategies, applied singly or in combination, that antagonize the injurious biochemical and molecular events that eventuate in irreversible ischemic injury. There has been a recent explosion of interest in this field, with over 1000 experimental papers and over 400 clinical articles appearing within the past 6 years. These studies, in turn, are the outgrowth of three decades of investigative work to define the multiple mechanisms and mediators of ischemic brain injury, which constitute potential targets of neuroprotection. Rigorously conducted experimental studies in animal models of brain ischemia provide incontrovertible proof-of-principle that high-grade protection of the ischemic brain is an achievable goal. Nonetheless, many agents have been brought to clinical trial without a sufficiently compelling evidence-based pre-clinical foundation. At this writing, around 160 clinical trials of neuroprotection for ischemic stroke have been initiated. Of the approximately 120 completed trials, two-thirds were smaller early-phase safetyfeasibility studies. The remaining one-third were typically larger (>200 subjects) phase II or III trials, but, disappointingly, only fewer than one-half of these administered neuroprotective therapy within the 4-6 hour therapeutic window within which efficacious neuroprotection is considered to be achievable. This fact alone helps to account for the abundance of "failed" trials.This review presents a close survey of the most extensively evaluated neuroprotective agents and classes and considers both the strengths and weakness of the pre-clinical evidence as well as the results and shortcomings of the clinical trials themselves. Among the agent-classes considered are calcium channel blockers; glutamate antagonists; GABA agonists; antioxidants/radical scavengers; phospholipid precursor; nitric oxide signal-transduction down-regulator; leukocyte inhibitors; hemodilution; and a miscellany of other agents. Among promising ongoing efforts, therapeutic hypothermia, high-dose human albumin therapy, and hyperacute magnesium therapy are considered in detail. The potential of combination therapies is highlighted. Issues of clinical-trial funding, the need for improved translational strategies and clinical-trial design, and "thinking outside the box" are emphasized. Part I: Neuroprotection -from Past to the PresentNeuroprotection for ischemic brain injury has emerged only recently as a topic of serious biomedical inquiry. A MEDLINE survey (PubMed, 2007) reveals virtually no publications on this topic until the early 1990's but a remarkable surge in publications over the past 10 years Correspondence and reprint requests to:

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Section: Part Ii: Neuroprotection --Moving From the Present Into The mentioning

confidence: 99%

Neuroprotection for ischemic stroke: Past, present and future

2008

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“…Numerous pharmacological agents 7,10,[16][17][18][19][20][21][22][23][24][25] (Table 2) that reduce the vasoconstriction and shivering thresholds have been used to manage shivering during therapeutic hypothermia. According to the ILCOR, 3 sedative and hypnotic agents are often used to decrease metabolic demand and facilitate mechanical ventilation in comatose patients who lack signs of awakening within the first 5 to 10 minutes after return of spontaneous circulation.…”

Section: Pharmacological Methodsmentioning

confidence: 99%

“…8 Disadvantages of meperidine use include risk of respiratory suppression, nausea and vomiting, and seizure potential with prolonged drug administration. 8 Recently, in a study 22 of combinations of drugs, meperidine and dexmedetomidine additively reduced the shivering threshold. However, a combination of buspirone and meperidine was even more beneficial in reducing the threshold because of the synergistic relationship of the drugs.…”

Section: Pharmacological Methodsmentioning

confidence: 99%

“…A close second was the combination of meperidine and buspirone, which synergistically reduced the shivering threshold by 2.0ºC, to 33.4ºC, an even lower temperature threshold for shivering. 22 Of note, buspirone is available only for oral administration and therefore is inappropriate for comatose patients. Nefopam and alfentanil additively reduced the shivering threshold by 1.8ºC, to 34.5ºC, 10 but nefopam is unavailable for use in the United States.…”

Section: Conclusion and Implications For Practicementioning

confidence: 99%

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Optimal Management of Shivering During Therapeutic Hypothermia After Cardiac Arrest

Logan

Sangkachand²,

Funk

2011

Critical Care Nurse

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Both pharmacological and nonpharmacological methods are used to control shivering in therapeutic hypothermia. An evidence-based protocol based on the most current research has been developed for the management of shivering during therapeutic hypothermia. Meperidine is the drug of choice and provides the greatest reduction in the shivering threshold. Other effective pharmacological agents recommended for reducing the threshold include dexmedetomidine, midazolam, fentanyl, and magnesium sulfate. In addition, skin counterwarming techniques, such as use of an air-circulating blanket, are effective nonpharmacological methods for reducing shivering when used in conjunction with medication. As a last resort, neuromuscular blocking agents are considered appropriate therapy for management of refractory shivering.

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“…Meperidine and buspirone administration was studied in human volunteers made hypothermic with an infusion of 4°C iv fluid, and significantly reduced the shivering threshold while causing little sedation or respiratory toxicity. 24 Intravenous meperidine administration inhibits shivering and decreases the rewarming rate in hypothermic human volunteers. 25 The administration of sedative infusions and neuromuscular blockers during hypothermia can complicate neurologic assessment in post-arrest patients, and may not be necessary if meperidine administration successfully inhibits shivering.…”

mentioning

confidence: 99%

Management following resuscitation from cardiac arrest: Recommendations from the 2003 Rocky mountain critical care conference

Bell

Brindley

Forrest

et al. 2005

Can J Anesth/J Can Anesth

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P Pu ur rp po os se e: : To propose a strategy for the management of patients admitted to critical care units after resuscitation from cardiac arrest.S So ou ur rc ce e: : Prior to the conference relevant studies were identified via literature searches and brief reviews circulated on the following topics: glucose and blood pressure management; therapeutic hypothermia; prearrest outcome prediction; post-arrest outcome prediction; and management of myocardial ischemia. Two days were devoted to assessing evidence and developing a management strategy at the conference. Consensus opinion of conference participants [intensive care unit (ICU) physicians] was used when high grade evidence was unavailable. Additional literature searches and data grading were performed post-conference. P Pr ri in nc ci ip pa al l f fi in nd di in ng gs s: : High grade evidence was lacking in most areas. Specific goals of treatment were proposed for: general care; neurologic care; respiratory care; cardiac care; and gastrointestinal care. There was adequate evidence to recommend therapeutic hypothermia for comatose patients who had witnessed ventricular fibrillation or ventricular tachycardia arrests. Conference participants supported extending therapeutic hypothermia to other presenting rhythms in selected circumstances. Additional goals included mean arterial pressure 80 to 100 mmHg, glucose 5 to 8 mmol·L -1 using insulin infusions, and PaO 2 > 100 mmHg for the first 24 hr. Absent withdrawal to pain 72 hr after resuscitation should prompt consideration of palliative care. The level of evidence for other recommendations was low.C Co on nc cl lu us si io on ns s: : The proposed management strategy represents an approach to manage patients in the ICU following resuscitation from cardiac arrest. Most of the recommendations are based on low grade evidence. Additional research is needed to improve the evidence base. A standard post-arrest management strategy could help facilitate future research. Objectif : Proposer une stratégie de traitement à adopter avec les patients admis aux unités de soins intensifs (USI) après la réanimation post-arrêt cardiaque. Source : Avant la conférence, les études utiles ont été repérées dans les publications et de brèves revues ont circulé sur

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Buspirone and Meperidine Synergistically Reduce the Shivering Threshold

Cited by 162 publications

References 36 publications

Neuroprotection for ischemic stroke: Past, present and future

Neuroprotection for ischemic stroke: Past, present and future

Optimal Management of Shivering During Therapeutic Hypothermia After Cardiac Arrest

Management following resuscitation from cardiac arrest: Recommendations from the 2003 Rocky mountain critical care conference

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