Thursday, February 25, 2010
Demerol is Not Bad, It Treats Shivering.
Image via WikipediaBut with the growth of induced hypothermia protocols in resuscitation efforts, palliative care teams are likely to be seeing Demerol to be used as a medication to prevent shivering.
So what is a palliative care team to do? We don't want a patient to shiver! Shivering is a symptom and an unpleasant one at that. And we want control symptoms, right? Shivering, oddly enough is not in the index of the 4th ed of the Oxford Textbook of Medicine. (Hint: If anyone needs me to write a chapter/pamphlet on shivering for the next edition I will!)
But we know Demerol is likely to cause delirium, myoclonus and seizures, especially in renal patients. And your induced hypothermia patient may be likely to have renal failure. So why do we even use Demerol for shivering?
I asked a lot of people in the hospital and no one had a decent explanation besides some versions of :
"It works for shivering."
"We use it in post-op. We always have."
And interestingly when pressed to tell me the second-line anti-shivering medication, the best I got was 'a warm blanket.' (Hopefully that should be first line for shivering.) So is a potentially dangerous medication like Demerol used for shivering merely based on anecdotal experience and medical cultural inertia?Treatment of shivering and the larger reduction of extreme vasoconstriction and sympathetic nervous system activation caused by induced hypothermia has been well studied...mostly in animal models. The reason for shivering is basically a thermoregulatory defense taht needs to be attenuated. And demerol reduces the shivering threshold, allowing patients to tolerate lower temps without shivering.
So what we do know about meperidine? It is active at the mu and kappa opioid receptors and is anticholinergic. Different articles cite the anti-shivering effect to be at either the mu-opioid, kappa-opioid or the alpha2-adrenorecptor (anti-cholinergic). So frankly we do not know how Demerol reduces anti-shivering, but we do have studies in healthy volunteers and anecdotal evidence to suggest it has a role in anti-shivering.
I hate to say more study is needed, and I REALLY don't want to say there is a paucity of data, but now at least we can all talk a little more intellectually about the drug choice for hypothermia protocols when palliative care is consulted. Maybe I should ask Drew if I can write a Palliative Care Aspects of Hypothermia Protocols EPERC Fast Fact.
And does anyone know the Latin (read Fancy Medical Term) for shivering?
Doufas, A. (2003). Dexmedetomidine and Meperidine Additively Reduce the Shivering Threshold in Humans Stroke, 34 (5), 1218-1223 DOI: 10.1161/01.STR.0000068787.76670.A4![Reblog this post [with Zemanta]](http://img.zemanta.com/reblog_e.png?x-id=3b040513-1394-4e3a-a5ce-94a230b4e1f0)
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17 Responses to “Demerol is Not Bad, It Treats Shivering.”
February 26, 2010
Rigors.
How about singultus/singulation for hiccup/hiccupping, sternus/sternutation for sneeze/sneezing, ructus/eructation for belch/belching?
February 26, 2010
Per the University of Notre Dame Latin dictionary and grammar aid (Latin words have gender, so one must do the proper declination for the context--thus the masculine/feminine/neuter endings):
"horridus -a -um [rough , shaggy, bristly; shivering with cold]. Transf., [wild, savage; unpolished, uncouth; frightful, horrible]. Adv. horride, [roughly]."
So, I guess I would go with "horridum" for generic shivering.
February 26, 2010
"Shiver" (same source):
"shiver
cohorresco -horrescere -horrui [to shudder or shiver].
horridus -a -um [rough , shaggy, bristly; shivering with cold]. Transf., [wild, savage; unpolished, uncouth; frightful, horrible]. Adv. horride, [roughly].
pavito -are intransit. [to shiver , tremble, quake with fear]; transit. [to quake at]."
February 26, 2010
Querquerus is "Shivering with cold". Also seems to apply to shivering with chills due to fever. (found at this website: http://archimedes.fas.harvard.edu/cgi-bin/dict?name=ls&lang=la&word=querquerus&filter=CUTF8 )
S.Grant
February 26, 2010
there are alot of persistent beliefs not supported by any evidence that occur in the hospital especially with regard to pain. This medical/surgical cultural landscape is buoyed by many old school docs and nurses who do things like give pain meds via IM injection preferentially, and they continue to use demerol like it's a wonder drug. Most of these folks have never heard of giving meds sub-Q or sublingually. They know nothing about equianalgesia. I've had an ICU nurse tell me once that she likes to hear her patients are having pain because that is a sign they are still alive.
February 26, 2010
I'm a K.I.S.S. kind of guy.
Rigors.
February 26, 2010
Thanks Brian, Pam and S.G for the Latin tips!
I like Horridum (or Horridus?) Querquerus looks cool, but it doesn't quite roll off the tongue does it? :)
Anon,
You are not alone in experiencing those things. The last comment by the nurse, is particularly frustrating, but I have heard that as well. Rare, but heard. I agree there is a lot of current practices that are not evidenced based, but when things are 'standard of care' it becomes VERY difficult to research or challenge the status quo. That is one of the reasons I like palliative medicine is that there is still a lot undiscovered and it is easier to be curious.
February 26, 2010
I know 'rigors' as an alternative name for shivering but for some reason it seemed to common to me that I may have overlooked it. I was hoping to find the more rarefied word.
But I agree with KISS in many facets of life. The only two exception I have is when you want to make things overly academic just for the sake of exercising your brain or you are playing legos with your children. Complexity is more funner!
February 26, 2010
Some formal medical terminology comes from French, e.g., râles for crackles heard on pulmonary auscultation, which incidently rhymes with "falls," and not with "pales," and debridement, pronounced "duhbreedmont." Some of the cool kids out East here are known to say, "sahntimeter" for centimeter. All this let's the hearer know just who's got enough schooling to know how to affect a Frahnsh accahnt.
Rigor(s) is another such term imported into English medicalese from the French, though much earlier (Middle English by way of Anglo-French) than the latter two.
February 27, 2010
In anesthesia, classical teaching about Demerol is that the drug renders the body somewhat poikilothermic, such that it's internal temperature varies with ambient temperature. In this way, the hypothalamus is "tricked" into not noticing the dropping temperature and therefore does not initiate the normal thermoregulatory mechanisms that induce shivering. The patient will be colder though, so active warming is needed.
March 01, 2010
Rigors.
The sort of bone-breaking rigors we experience in Oncology require demerol. Period. (Often, Onc and PC are one and the same where I work.)
It's a relief to have our standard of care validated in any respectable way, since we are the 'oddballs' in the hospital setting.
My pharm courses were taught by an old-school Doc who was keen on the 'demerol promotes poikilothermia' idea, as well.
We have better, safer drugs for pain. But please allow us to continue to use demerol for rigors. There are few things more frightening for the patient, and heart-wrenching for THIS nurse.
March 02, 2010
I am a hem/onc/pall doc, or what we call a HOP doc! We have been using morphine for rigors, in an attempt to get meperidine off the general formulary, and it works just as well, but that is anecdotal. Doubt the study will ever be done!
Have a fun time at AAHPM!!
March 02, 2010
The Tosca commentary was wonderful! What a creative interface between opera and palliative care. Thank you! Sadly, no, TRAGICALLY (of course, we're talking opera here!), The youtube link was not there. but easy enough to search!
March 02, 2010
I like Horridum or Horridus or whatever you call. Looks pretty cool to me. :)
March 06, 2010
I never thought I would say this but I just used Demerol on the Oncology floor. It's actually banned from our formulary but still exists in small amounts on the Oncology floor. We never used it during my HPM fellowship training but a nurse begged me to use it as one of the patients with MM developed SEVERE rigors. I ok'd 25mg and gosh darn it...IT WORKED WELL!!! Geez, now I'm stuck, LOL.
March 08, 2010
Hospicephysician, by the powers invested in me by Google and the Blogosphere, your sins are forgiven for occasionally using meperidine.
My own thoughts about this is that no drug is evil; all drugs are useful poisons; and it just so happens that demerol is an effective analgesic with uniquely nasty toxicities. And because it's impossible (usually) to get people to change their practice based on evidence or at least rational pharmacology (ie we have equally effective and far safer analgesics available) many institutions just up and banned it to protect their patients from stubborn clinicians. All good, but it doesn't mean demerol is evil, and it doesn't change the fact that it might have unique benefits for (particularly drug-related) rigors. Don't know that for sure of course. I think as a resident or maybe a fellow I did a lit review on it and found very little in the way of *real* clinical data (in vitro stuff about cytokines, poikilothermia in rats, etc.) and certainly none actually comparing demerol to other opioids for rigors. All this said, I know of no reason to think that *occasional* dosing of demerol in patients without renal insufficiency is any cause for concern, and in the absence of data to point us one way or the other (aside from Laurie intriguing anecdote that other opioids work just as well) I think allowing it to be used in a highly restricted setting is useful.
I think about it this way: the world will be a better place if by the time I end my practice morphine, oxycodone, hydromorphone, fentanyl, etc. are considered dangerous/morally suspect drugs by younger clinicians who never used them. Not because we live in some opio-phobic/backlash but because they've been superceded by drugs which are clearly superior: opioids we can only dream of now which provide good analgesia but no/lower risk of sedation, pruritus, respiratory depression, hyperalgesia, etc. Some grizzled Christian Sinclair will be hoarding a supply of morphine out of reach of the hospital pharmacist saying 'Consarnit there's just nothing like morphine to palliative dyspnea at the end of life! Di-levo-gamma-muergib just doesn't cut it! Leave me my morphine!' That will be a good day.
March 09, 2010
Drew, great comment. The two statements that had me laughing hard were "Hospicephysician, by the powers invested in me by Google and the Blogosphere, your sins are forgiven for occasionally using meperidine." and "Some grizzled Christian Sinclair will be hoarding a supply of morphine out of reach of the hospital pharmacist saying 'Consarnit there's just nothing like morphine to palliative dyspnea at the end of life!" Anyway, great comments from everyone all around. I agree, use on a case by case basis would seem the most obvious use for Demerol just as the use of Methadone is not for everyone. Thanks again!
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