Pancuronium or vecuronium for treatment of shivering after cardiac surgery

This randomized double-blind study compared the hemodynamic and metabolic effects of pancuronium and vecuronium during treatment of shivering after cardiac surgery with hypothermic cardiopulmonary bypass. Thirty sedated and pain-free patients who shivered after cardiac surgery were treated with pancuronium (n = 15) or vecuronium (n = 15) 0.08 mg/kg. Baseline values of heart rate (HR), mean arterial pressure, arterial and venous blood gases, total body oxygen consumption indexed to body surface area (VO2-I), and pressure work index (PWI, an estimate of myocardial oxygen consumption) were measured on arrival in the intensive care unit, at onset of shivering, and repeatedly for 2 h after treatment. Continuous ST segment analysis of leads II and V5 were used for detection of myocardial ischemia. Treatment of shivering with pancuronium decreased VO2-I by 32% (P = 0.0001). This was accompanied by a 14% increase in HR (P = 0.001) and a 10% increase in PWI (P = 0.03). Vecuronium decreased VO2-I by 36% (P = 0.003) with a 4% decrease in HR (P = 0.04) and a 6% decrease in PWI (P = 0.06). Myocardial ischemia (n = 3) and ventricular arrhythmias (n = 3) occurred in five patients treated with pancuronium. Only one patient treated with vecuronium had ventricular arrhythmia (P = 0.08). Seven patients treated with pancuronium and eight treated with vecuronium were taking beta-adrenergic blockers preoperatively which was associated with lower HR (96 +/- 16 vs 109 +/- 15 bpm; P = 0.025) and lower PWI (8.8 +/- 1.2 vs 10.7 +/- 1.92 mL.min-1 x 100 g-1; P = 0.003) at onset of shivering. However, beta-adrenergic blockers did not attenuate the relative HR increase induced by pancuronium. No relationship was found between hypercapnia and tachycardia or hypertension. These results suggest that, when compared to pancuronium for treatment of postoperative shivering, vecuronium may be advantageous because it does not increase myocardial work. The disproportionate relationship between VO2-I and PWI after treatment with muscle relaxants indicates that increased VO2-I does not contribute significantly to the hemodynamic disturbances associated with shivering. These disturbances are more likely the results of increased adrenergic activity related to pain and recovery from anesthesia. Shivering and its associated hemodynamic disturbances appear to be concomitant but independent signs of awakening.