Clonidine versus tramadol for post spinal anesthesia shivering: A meta-analysis of randomized controlled trials

Jinguo Wang; Haixiao Zhao; Yanhui Li; Rui Wang; Na Wang

doi:10.15537/smj.2021.42.4.20200342

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Figure 1
- Flow chart of selected randomized controlled trials.
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Figure 2
- Risk of bias evaluation.
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Figure 3
- A) Forest plot for effective rate of shivering control, B) and recurrent rate of shivering.
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Figure 4
- Forest plot for related complications (hypotension, bradycardia, sedation, nausea, vomiting, dizziness, dry mouth).

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Table 1

- Characteristics of the included trials.

Author/date	Dosage	Study type	Jadad score	Sample size D/T	Patient characteristics; surgical setting	Type of anesthesia; drug for anesthesia	Degrees of shivering	Outcomes measures
Shukla et al⁶ 2011	Clonidine 0.5μg/kg; tramadol 0.5 mg/kg	RCT	4	40/40	18-40 yr, ASA: I; Elective abdominal, orthopaedic and gynaecological surgeries	Spinal anesthesia; 0.5% bupivacaine 10-15 mg	Grades 3 or 4	1, 2, 3, 4, 5, 6, 7, 8
Vyas et al⁷ 2018	Clonidine 1 μg/kg; tramadol 1 mg/kg	RCT	4	30/30	18-65 yr, ASA: I-II; Elective lower abdominal and lower limb surgeries	Spinal anesthesia; 0.5% heavy bupivacaine	Grades 1-4 for at least 2 minutes	1, 2, 3, 4, 5, 6, 7, 8
Venkatraman et al⁸ 2018	Clonidine 1 μg/kg; tramadol 1 mg/kg	RCT	5	30/30	18-70 yr, ASA: I-II; Lower abdominal, lower limb, orthopaedic and plastic surgeries	Spinal anesthesia; No mention	Grades 2, 3 or 4	1, 2, 3, 4, 5, 6,
Bansal & Jain⁹ 2011	Clonidine 150μg; tramadol 50 mg	RCT	4	30/30	18-65 yr, ASA: I-III; Urological, inguinal, and lower limb surgeries	Spinal anesthesia; 0.5% heavy bupivacaine 3.2-3.5 mL	Grade 2 or 3	1, 2, 3, 5, 6,
Verma & Kumar¹⁰ 2016	Clonidine 0.5μg/kg; tramadol 1.5 mg/kg (maximum 100mg)	RCT	3	30/30	18-45 yr, ASA: I-II; Elective abdominal, gynecological and orthopedic surgeries	Spinal anesthesia; 0.5% heavy bupivacaine 15 mg	Grade 2, 3 or grade 4	1, 2, 3, 4, 5, 6
Attal et al¹¹ 2015	Clonidine 50μg; tramadol 50 mg	RCT	3	30/30	18-40 yr, ASA: I-II; Elective lower abdominal and lower limb surgeries	Spinal anesthesia; 0.5% heavy bupivacaine 3.5 mL	Grade 3 or 4 for at least 2 minutes	1, 2, 3, 4, 5, 6, 8
Reddy & Chiruvella¹² 2011	Clonidine 50μg IV; tramadol 50 mg IV	RCT	4	45/45	18-35 yr, ASA: I-II; Elective or emergency caesarean section	Spinal anesthesia; 0.5% heavy bupivacaine 10 mg	Grade 3 or 4 for at least 3 minutes	1, 2, 4, 5, 6, 8
Kulshrestha¹³ 2014	Clonidine 50μg IV; tramadol 50 mg IV	RCT	4	45/45	18-35 yr, ASA: I-II; Elective Elective Lower Segment Caesarean Section	Spinal anesthesia; 0.5% bupivacaine 12mg	Grade 3 or 4 for at least 3 minutes	1, 2, 3, 4, 5, 6, 7, 8
Aravind et al¹⁴ 2014	Clonidine 1 μg/kg; tramadol 1 mg/kg IV	RCT	4	40/40	18-40 yr, ASA: I-II; Various surgeries	Spinal anesthesia; 0.5% heavy bupivacaine	Grade 2, 3 or grade 4 for at least 2 minutes.	1, 2, 5
Longani et al¹⁵ 2017	Clonidine 150μg IV; tramadol 50 mg IV	RCT	3	40/40	25-50 yr, ASA: I-II; Elective lower stomach and lower appendage surgeries,	Spinal anesthesia; 0.5% bupivacaine 14 mg	Grade 3 or 4 for at least 2 minutes	1, 2, 3, 4, 5, 8
Jois et al¹⁶ 2016	Clonidine 0.5μg/kg IV; tramadol 0.5 mg/kg IV	RCT	4	40/40	25-50 yr, ASA: I-II; Lower abdominal and lower limb surgeries	Spinal anesthesia 0.5% heavy bupivacaine 2-4mL	Grade 3 or 4	1, 2, 3, 4, 5, 6, 7, 8
Singh et al¹⁷ 2016	Clonidine 0.5μg/kg IV; tramadol 0.5 mg/kg IV	RCT	4	30/30	20-50 yr, ASA: I-II; elective lower abdominal, lower limb orthopaedic and gynaecological surgeries	Spinal anesthesia 0.5% heavy bupivacaine 15 mg	Grade 3 or 4	1, 2, 3, 4, 5, 6, 8
Ali & Debata¹⁸ 2017	Clonidine 50μg IV; tramadol 50 mg IV	RCT	3	30/30	18-60 yr, ASA: I-II; elective lower abdominal and lower limb surgery under spinal anesthesia	Spinal anesthesia 0.5% heavy bupivacaine	Grade 1, 2 or 3	2, 5
Kumar et al¹⁹ 2016	Clonidine 0.6μg/kg IV; tramadol 1.0 mg/kg IV	RCT	3	20/20	18-60 yr, ASA: I-II; elective lower abdominal surgeries,orthopaedics lower limb surgeries and plastic surgeries.	Spinal anesthesia 0.5% heavy bupivacaine 15 mg	Grades 3 or 4	3

RCT: randomized controlled trial, ASA: American Society of Anesthesiologists, YR: year, IR: intravenous, Outcome measures: 1) Effective rate of shivering control, 2) Time to cease shivering, 3) Recurrent rate of shivering, 4) The incidence of bradycardia and hypotension, 5) The incidence of nausea and vomiting, 6) The incidence of sedation, 7) The incidence of dizziness, 8) The incidence of dry mouth