Pt if feeling cold + shivering what can we give?
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Here's a concise clinical answer on managing a patient who is feeling cold and shivering:
Management of Shivering / Feeling Cold
Why it matters
Shivering significantly increases oxygen consumption, catecholamine release, cardiac output, heart rate, blood pressure, and intracranial/intraocular pressure — increasing cardiovascular morbidity, especially in older patients.
First-line: Non-pharmacological (Prevention is optimal)
- Warm blankets / forced-air warming
- Warm IV fluids
- Minimize thermal loss (the primary cause is perioperative/environmental hypothermia)
Pharmacological Options
| Drug | Dose | Notes |
|---|---|---|
| Meperidine (Pethidine) | 12.5–35 mg IV | Drug of choice — uniquely effective among opioids; disproportionately reduces the shivering threshold via α₂β-adrenoceptor activity |
| Tramadol | 0.5 mg/kg IV (35–220 mg range) | As effective as meperidine in studies; good alternative |
| Clonidine | Low dose IV | α₂-agonist; useful adjunct |
| Ondansetron | Standard antiemetic dose | Also has anti-shivering properties |
| Ketamine | 0.5 mg/kg | Useful when shivering is remifentanil-induced; prevents opioid-tolerance-related shivering |
Key Points
- Meperidine is the classic go-to drug for acute shivering — its anti-shivering mechanism is unique and distinct from its opioid analgesic effect.
- Tramadol (0.5 mg/kg) is equally effective in evidence-based trials and avoids meperidine's serotonergic risks.
- Avoid meperidine in patients on MAOIs (risk of serotonin syndrome).
- In post-anesthetic shivering from remifentanil, ketamine infusion is preferred.
— Miller's Anesthesia, 10e, p. 2733–2734; Morgan & Mikhail's Clinical Anesthesiology, 7e, p. 2116
Inj. Hydrocort dose in adult patint
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The textbooks didn't return a direct hydrocortisone dosing table, so here is the well-established clinical reference data:
Inj. Hydrocortisone (Hydrocortisone Sodium Succinate) — Adult Doses
By Indication
| Indication | Dose | Route | Frequency |
|---|---|---|---|
| Anaphylaxis / Allergic emergency | 200 mg | IV slow bolus | Stat; repeat 4–6 hourly if needed |
| Acute adrenal crisis (Addisonian crisis) | 100 mg stat, then 100 mg every 6–8 hrs | IV | For 24–48 hrs, then taper |
| Stress dosing (surgical cover) | 100 mg at induction, then 50–100 mg every 8 hrs | IV/IM | For 24–48 hrs |
| Septic shock (refractory) | 200–300 mg/day in divided doses or continuous infusion | IV | Until vasopressors weaned |
| Severe asthma / Status asthmaticus | 100–200 mg | IV | Every 6 hrs |
| Cerebral edema / Acute inflammation | 100–500 mg | IV slow infusion | Every 2–6 hrs depending on response |
Administration
- Give slowly IV over 2–5 minutes (rapid bolus can cause cardiovascular collapse, especially at high doses)
- Can also be given IM when IV access unavailable
- Reconstitute with water for injection or Normal Saline
Key Points
- The standard "stat" dose in most emergencies = 100–200 mg IV
- In adrenal crisis, always give IV fluids (0.9% NaCl) simultaneously
- Once stable, convert to oral hydrocortisone and taper
- Maximum daily dose used in critical illness: up to 300–400 mg/day
Quick memory aide: "100 mg for stress, 200 mg for anaphylaxis, 300 mg/day for septic shock"
What investigation should be advise in ascites and what could be treatment modalities
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Here is a comprehensive overview of ascites — investigations and treatment:
Ascites — Investigations & Treatment
Investigations
History & Examination
- Shifting dullness, fluid thrill, everted umbilicus
- Look for signs of underlying cause: jaundice, spider naevi, splenomegaly (cirrhosis); cachexia (malignancy); raised JVP (cardiac)
Bedside / Imaging
| Investigation | Purpose |
|---|---|
| Abdominal Ultrasound | Confirms ascites (even small amounts), assesses liver morphology (cirrhosis), splenomegaly, portal vein size, liver lesions |
| CT Abdomen | Better characterization of cause — masses, lymphadenopathy, peritoneal deposits (malignancy) |
| CXR | Pleural effusion (hepatic hydrothorax), cardiac causes |
| ECG / Echo | Rule out cardiac cause (right heart failure, constrictive pericarditis) |
Blood Tests
| Test | Purpose |
|---|---|
| LFTs, Bilirubin, PT/INR | Liver function, synthetic dysfunction |
| Serum Albumin | Needed to calculate SAAG |
| CBC | Anaemia, thrombocytopenia (portal hypertension) |
| Urea, Creatinine, Electrolytes | Renal function (hepatorenal syndrome risk) |
| Serum Protein | For SAAG calculation |
| Viral hepatitis screen (HBsAg, Anti-HCV) | Cirrhosis aetiology |
| Tumour markers (AFP, CEA, CA-125) | Malignant ascites |
| TFTs | Hypothyroidism as rare cause |
| ANA, AMA, ASMA | Autoimmune hepatitis, PBC |
Diagnostic Paracentesis (most important investigation)
Send fluid for:
| Test | What it tells you |
|---|---|
| SAAG (Serum-Ascites Albumin Gradient) | ≥1.1 g/dL = portal hypertension (cirrhosis, cardiac); <1.1 = non-portal (malignancy, TB, pancreatitis) |
| Total protein | High protein + low SAAG = infection/malignancy |
| Cell count & differential | PMNs ≥250/mm³ = Spontaneous Bacterial Peritonitis (SBP) |
| Culture & sensitivity | SBP organism identification |
| Cytology | Malignant cells |
| LDH, Glucose | Exudate vs transudate differentiation |
| Amylase | Pancreatic ascites |
| AFB / ADA | Tuberculous peritonitis |
Treatment Modalities
1. Treat the Underlying Cause
- Cirrhosis → antiviral (HBV/HCV), alcohol abstinence
- Malignancy → chemotherapy if responsive
- Cardiac → heart failure management
2. Dietary Restriction
- Sodium restriction: ≤2 g/day (2000 mg Na)
- More restrictive diets not recommended — compromise nutrition
- Fluid restriction only if serum Na <130 mEq/L
3. Diuretics (mainstay of pharmacological treatment)
| Drug | Starting Dose | Max Dose | Notes |
|---|---|---|---|
| Spironolactone (1st line) | 100 mg/day (morning) | 400 mg/day | Aldosterone antagonist; more effective than loop diuretics alone |
| Furosemide (add-on) | 40 mg/day | 160 mg/day | Add if tense ascites, inadequate weight loss, or hyperkalemia |
| Ratio | 100 mg spiro : 40 mg furo | — | Standard ratio to maintain normokalemia |
Target weight loss:
- Week 1: 1 kg/week
- Thereafter: 2 kg/week
- Do NOT exceed 0.5 kg/day (no edema) or 1 kg/day (with edema)
Avoid: ACE inhibitors, ARBs, NSAIDs (worsen renal function)
4. Therapeutic / Large-Volume Paracentesis (LVP)
- For tense or refractory ascites
- Remove 4–6 L per session (or all fluid)
- Always give IV Albumin: 6–8 g per litre removed (especially >5 L) to prevent paracentesis-induced circulatory dysfunction (PICD)
5. Albumin Infusion (long-term)
- 40 g twice weekly × 2 weeks, then 40 g weekly
- Added to spironolactone + furosemide → reduces recurrent ascites and improves 18-month survival
6. TIPS (Transjugular Intrahepatic Portosystemic Shunt)
- For refractory ascites (requiring LVP >2×/month)
- PTFE-covered TIPS improves survival
- Risk: hepatic encephalopathy (higher with uncovered stents)
7. Peritoneovenous Shunt
- For patients not candidates for TIPS or liver transplant
- Subcutaneous silicone tube transfers ascitic fluid to systemic circulation
8. SBP — if diagnosed
- Cefotaxime 2 g IV every 8 hrs (or ceftriaxone) × 5 days
- Albumin 1.5 g/kg on day 1 + 1 g/kg on day 3 — prevents hepatorenal syndrome
- SBP prophylaxis: Norfloxacin 400 mg/day or Ciprofloxacin 500 mg/day
9. Liver Transplantation
- Definitive treatment for refractory ascites from end-stage liver disease
- Ascites + hepatorenal syndrome = priority for transplant listing
— Goldman-Cecil Medicine, 2-Vol Set; Rosen's Emergency Medicine, 10e; Sleisenger & Fordtran's GI & Liver Disease
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