The Effect of Prophylactic Steroids on Shivering in Adults Undergoing Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND: Shivering is common following anesthesia and surgery. Corticosteroids (steroids) have been tried to reduce the risk of shivering, but the evidence in favor of their use is uncertain. The primary objective of this review was to evaluate the effect of steroids on the risk of perioperative (intra- and postoperative) shivering versus controls (placebo and active controls). Additional objectives were to assess the risk of severity of shivering, patient satisfaction with shivering prophylaxis, quality of recovery (QoR), and the risk of steroid-related adverse effects. METHODS: PubMed, Embase, Cochrane Central Registry of Trials, Google Scholar, and preprint servers were searched from inception until November 30, 2022. Randomized controlled trials (RCTs) published in the English language were retrieved, provided they reported on shivering either as a primary or secondary outcome following steroid prophylaxis in adult patients undergoing surgery under spinal or general anesthesia. RESULTS: A total of 3148 patients from 25 RCTs were included in the final analysis. The steroids used in the studies were either dexamethasone or hydrocortisone. Dexamethasone was administered intravenously or intrathecally, while hydrocortisone was administered intravenously. Prophylactic administration of steroids reduced the risk of overall shivering (risk ratio [RR], 0.65 [95% confidence interval {CI}, 0.52–0.82]; P = .0002; I 2 = 77%) as well as the risk of moderate to severe shivering (RR, 0.49 [95% CI, 0.34–0.71]; P = .0002; I 2 = 61%) in comparison to controls. Administration of intravenous dexamethasone (RR, 0.67 [95% CI, 0.52–0.87]; P = .002; I 2 = 78%) and hydrocortisone (RR, 0.51 [95% CI, 0.32–0.80]; P = .003; I 2 = 58%) were effective in shivering prophylaxis. For intrathecal dexamethasone (RR, 0.84 [95% CI, 0.34–2.08]; P = .7; I 2 = 56%), the null hypothesis of no subgroup difference was not rejected ( P = .47), preventing definitive conclusions about the efficacy of this route of administration. The prediction intervals for both overall shivering risk (0.24–1.70) and risk of severity of shivering (0.23–1.0) precluded generalization of results in future studies. Meta-regression analysis was used to further explore heterogeneity. Factors like the dose and timing of administration of steroids or the type of anesthesia were not found to be significant. Patient satisfaction and QoR were higher in the dexamethasone groups versus placebo. No increased risk of adverse events of steroids was noted versus placebo or controls. CONCLUSIONS: Prophylactic steroid administration may be beneficial in reducing the risk of perioperative shivering. However, the quality of evidence in favor of steroids is very low. Further well-designed studies are needed for establishing generalization.