Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 76083

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : June | Volume : 17 | Issue : 6 | Page : UC11 - UC14 Full Version

Effects of Nalbuphine and Nefopam in the Management of Postoperative Shivering after Laparoscopic Cholecystectomy under General Anaesthesia: A Randomised Double-blind Study

Published: June 1, 2023 | DOI:
Nahila Mahajan, Rajesh Angral, Anshuman Mahesh Chander, Raj Rishi Sharma

1. Assistant Professor, Department of Anaesthesiology, Government Medical College, Kathua, UT of Jammu and Kashmir, India. 2. Associate Professor, Department of Anaesthesiology, Government Medical College, Kathua, UT of Jammu and Kashmir, India. 3. Assistant Professor, Department of Surgery, Government Medical College, Kathua, UT of Jammu and Kashmir, India. 4. Professor, Department of Surgery, Government Medical College, Kathua, UT of Jammu and Kashmir, India.

Correspondence Address :
Dr. Rajesh Angral,
Plot No. 176, Housing Colony Janipur, Jammu-180007, UT of Jammu and Kashmir, India.


Introduction: Postoperative shivering is a very common and unpleasant complication of laparoscopic surgery under General Anaesthesia (GA). Postoperative shivering is uncomfortable for the patient, and it might increase the postoperative complications especially in high-risk patients.

Aim: To compare the therapeutic effects of nalbuphine and nefopam in treating postoperative shivering in patients undergoing Laparoscopic Cholecystectomy (LC) under GA.

Materials and Methods: The present study was a randomised, double-blinded, study conducted in the Department of Anaesthesiology and Surgery on 60 ASA Grade-I and II physical status scheduled for elective LC under GA, who developed postoperative shivering during recovery from GA, at Government Medical College and Hospital, Kathua, Jammu and Kashmir, India. A total of 60 patients aged between 25 to 60 years, American Society of Anaesthesiologists (ASA) I and II scheduled for elective LC under GA, who had postoperative shivering during recovery period. Study duration was of one year (October 2021 to October 2022). Patients were randomly allocated into group A (n=30, received nalbuphine) and group B (n=30, received nefopam). Data was collected and compiled using Statistical Package for the Social Sciences (SPSS) version 23.0. Student’s t-test and Chi-square test was used to analyse the data. The p-value <0.05 was considered as statistically significant.

Results: Time for cessation of shivering was 4.11±1.12 minutes in nalbuphine group as compared to 3.03±0.68 minutes in nefopam group which was statistically significant (p=0.001). Response rate was 73.33% in nalbuphine group as compared to 90% in nefopam group, and the difference was statistically significant (p=0.043). Similar incidence of bradycardia and vomiting was noted in both the groups. Nausea (6.67% vs 3.33%), pain on injection (3.33% vs nil) and pruritis (6.67% vs nil) were more in nalbuphine group as compared to nefopam group which was statistically significant. Sedation was more in nalbuphine group as compared to nefopam group (10% vs 6.67%) which was not significant statistically.

Conclusion: Nefopam as compared to nalbuphine had earlier cessation of shivering, better response rate and had less side-effects.


Grades of shivering, Hypothermia, Thermoregulation

Postanaesthetic shivering is defined as an involuntary movement of one or more muscle groups in the early recovery phase following general or regional anaesthesia which is the leading cause of discomfort for postsurgical patients (1). Postanaesthetic shivering is a common experience among patients recovering from the comforts of modern regional or GA and is even worse than postoperative surgical pain (2). Postanaesthesia shivering occurs in 20-70% after GA (3). Most of the times, it is preceded by central hypothermia and peripheral vasoconstriction, indicating that it is almost a thermoregulatory mechanism, which even today is less understood (4). Shivering is uncomfortable for the patient and also interferes with monitoring in the recovery. Shivering can increase metabolic requirement, which might be deleterious for patients with fixed cardiac output and limited respiratory reserves (5). Moreover the incidence of shivering is more in laparoscopic surgeries because of the convection effects produced by cool CO2 (20.1°C) flow inside the peritoneal cavity (6). There are various methods available to control shivering during anaesthesia, which include non pharmacological methods and pharmacological methods using drugs which have antishivering properties. Non pharmacological methods using equipment such as covering with drapes (by blanket), using radiant heat and warming up operating rooms to maintain the normal temperature of the body are effective (7). Other non pharmacological methods which use specialised equipments to prevent or to control shivering are expensive and are not practical in all clinical settings. The pharmacological methods using drugs like pethedine, nalbuphine, tramadol, clonidine, doxapram, katanserin, nefopam, etc., are simple, cost-effective and easy to implement (8),(9). Despite the availability of many drugs, it still continues to be an ongoing problem in Post Anaesthesia Care Unit (PACU).

Nalbuphine is a mixed agonist-antagonist opioid with κ-agonist activity and it antagonises side-effects of μ-agonists (10). Nalbuphine results in an uncharacteristically large reduction in the shivering threshold than the exaggerated generalised thermoregulatory inhibition (11). Studies have shown nalbuphine to be better than tramadol in controlling shivering with faster onset and better sedation with less side-effects (12),(13). Nefopam is a non opiate, benzoxazocine substance (14). Nefopam is a synaptic reuptake inhibitor of dopamine, norepinephrine and serotonin and effects thermoregulatory response via α2 adrenoceptors (15). Commonly used drugs for postoperative shivering like tramadol, meperidine have high incidence of side-effects. So, there is a need to find drugs as effective but with less side-effects. Both the study drugs are in use since long as analgesics and both the drugs had been studied differently by many researchers as having antishivering effects after anaesthesia (16),(17),(18). To the best of the author’s knowledge there is hardly any study comparing nalbuphine with nefopam for the control of postoperative shivering. Present study was aimed to compare the therapeutic effects of nalbuphine and nefopam in preventing postoperative shivering in LC under GA.

Material and Methods

Present study was a randomised, double-blinded study, conducted in the Department of Anaesthesiology and Surgery on 60 ASA Grade-I and II physical status scheduled for elective LC under GA, who developed postoperative shivering during recovery from GA, at Government Medical College and Hospital, Kathua, Jammu and Kashmir, India. Study duration was of one year from October 2021 to October 2022. The study was commenced after approval from Institutional Ethical Committee (IEC) (IEC/GMCK/87/Pharma dated 25/8/2021). After explaining the patients in their local language, written consent was taken for participation in the study, during preanaesthetic evaluation.

Inclusion criteria: A total of 60 patients belonging to ASA Grade-I and II of either gender aged 25 to 60 years, who were scheduled for elective LC under GA and developed postoperative shivering during recovery period from GA were enrolled in the study after taking informed consent.

Exclusion criteria: Patients with body temperature more than 37.5°C, allergy to any of the study drug, history of muscular disorders, convulsions and those with body temperature less than 36.5°C at extubation were excluded from the study.

Sample size calculation: Sample size was calculated on the basis of previous studies. Incidence of postoperative shivering was 20-70% (3),(19). A sample size of approximately, 30 in each group was needed to demonstrate the effectiveness of nalbuphine and nefopam in reducing shivering by 50% with 95% confidence (α-0.05) and the power of the study being 80%.

All patients who fulfilled the inclusion criteria were enrolled and randomised using computer generated chart with allocation ratio of 1:1 into either of the two groups.

• Group A (n=30) received intravenous (i.v.) nalbuphine (0.07 mg/kg)
• Group B (n=30) received i.v. nefopam (0.15 mg/kg).

The Consolidated Standards of Reporting Trials (CONSORT) diagram is shown in (Table/Fig 1).

Patient’s age (years), weight (Kg), Body Mass Index (BMI) (Kg/m2), gender (male/female), ASA grade were recorded. Induction of anaesthesia was done using propofol 2 mg/kg, vecuronium 0.08 mg/kg and fentanyl (1-2 μg/kg). The trachea of all the patients was intubated with an appropriate sized endotracheal tube, and maintenance of anaesthesia was done with isoflurane 12and vecuronium. Neuromuscular blockade was reversed with glycopyrrolate and neostigmine. Warm fluids were used intraoperatively and operating room temperature was maintained at approx 22°C. Basic monitoring was done intraoperatively. In the recovery room, patients were observed for occurrence of shivering and grades of shivering were assessed. Grading of the shivering was carried out by a scale similar to that validated by Crossley AWA and Mahajan RP (20) (Table/Fig 2).

Both the patients and the anaesthesiologist assessing the shivering grades were blinded to the study drug used. Both the study drugs were prepared by another anaesthesiologist who was not involved in the study. Single bolus dose of either i.v. nefopam (0.07 mg/kg) or i.v. nalbuphine (0.15 mg/kg) was given to treat shivering Grade 2, 3, 4. Shivering grade was further evaluated at 10, 20 and 30 minutes after the study drug administration.

All patients in the recovery room were attached to basic monitors and baseline Oxygen Saturation (SpO2), Heart Rate (HR), Mean Arterial blood Pressure (MAP), and axillary temperature were measured and measurements repeated every 10 minutes. Time to disappearance of shivering noted after administration of either of the study drugs. Response to treatment was considered if shivering ceased within 20 minutes of drug administration, if not it was considered as incomplete response. In the patients with incomplete response, rescue dose of i.v. Tramadol (1 mg/kg) was given. Any adverse side-effects like nausea, vomiting, pruritis, sedation were recorded.

Statistical Analysis

Data was collected and compiled using Microsoft Excel, analysed using SPSS version 23.0. Frequency, percentage, means and Standard Deviations (SD) was calculated for the continuous variables, while ratios and proportions were calculated for the categorical variables. Difference of proportions between qualitative variables was tested using Student’s t-test and Chi-square test or Fisher-exact test as applicable. The p-value <0.05 were considered as statistically significant.


In the present study, 60 patients were randomly allocated into group A (n=30, received nalbuphine) and group B (n=30, received nefopam). There was no statistically significant difference (p>0.05) noted in both groups with respect to age (years), weight (Kg), BMI (Kg/m2), gender (male/female), ASA grade and duration of surgery (Table/Fig 3).

Regarding axillary temperature (°C) at baseline,10, 20 and 30 minutes after the study drug administration were comparable among both groups and the difference was not statistically significant (p>0.05) (Table/Fig 4).

As far as HR (beats per minute) at baseline,10, 20 and 30 minutes after the study drug administration was concerned, were comparable among both groups and no statistically significant difference was noted (p>0.05) (Table/Fig 5).

In present study, MAP (mmHg) at baseline, 10, 20 and 30 minutes after the study drug administration were comparable in both groups with no statistically significant difference (p>0.05) (Table/Fig 6).

In present study, partial pressure of SpO2 at baseline,10, 20 and 30 minutes after the study drug administration were comparable in both groups with no statistically significant difference (p>0.05) (Table/Fig 7).

Time for cessation of shivering was 4.11±1.12 minutes in nalbuphine group as compared to 3.03±0.68 minutes in nefopam and difference was statistically significant (p=0.001) (Table/Fig 8). Response rate to shivering was statistically significant (p=0.043) (Table/Fig 8). Incomplete response was statistically significant (Table/Fig 8). Similar incidence of bradycardia and vomiting was noted in both groups. Nausea (6.67% vs 3.33%), pain on injection (3.33% vs nil) and pruritis (6.67% vs nil) were more in nalbuphine group as compared to nefopam group and difference was statistically insignificant (Table/Fig 9). Sedation was more in nalbuphine group as compared to nefopam group (10% vs 6.67%) but difference was not significant statistically (Table/Fig 9).


The main causes of shivering intra or postoperative are temperature loss, decreased sympathetic tone and systemic release of pyrogens (21). Intraoperative hypothermia can be minimised by any technique that limits cutaneous heat loss to the environment such as those due to cold operating room, evaporation from surgical incisions and conductive cooling produced by administration of cold iv fluids (22). Following risk factors predispose the patient to hypothermia and shivering: young age, male gender, low body weight, or poor nutritional status, prolonged preoperative fasting, an ASA grade greater than 1, combined general-regional anaesthesia and the extent of induced sympathetic blockade, administration of premedication, volatile anaesthetics, and muscle relaxants, temperature of operating room and i.v. fluids (23).

The results of present study showed the superiority of nefopam over nalbuphine in the treatment of postoperative shivering as shown by earlier cessation of shivering and higher response rate. Present study findings were in contrast to the study conducted by Megalla SA and Mansour HS who observed that the mean response time for control of shivering in nalbuphine group was 3.56±0.82 minutes with success rate of 92% and relapse rate was 8.7% in patients after spinal anaesthesia (24). However, in present study response time was 4.11±1.12 minutes with success rate of 73.33% and relapse rate of 26.67%. This could be because of more incidence of shivering after laparoscopic surgery.

Taneja P et al., used nalbuphine in a dose of 0.3 mg/kg for the control of shivering after spinal anaesthesia in caesarean section and observed the response rate to shivering of 90% and recurrence of shivering in 20% of patients (16). This result was in contrast to present study findings, which could be because present study have used lesser dose of nalbuphine (0.07 mg/kg). Lv M et al., in their meta-analysis observed that prophylactic administration of nefopam significantly reduced the risk of perioperative shivering not only in the patients under GA but also neuraxial anaesthesia (95%), which was slightly more than present study, since present study used nefopam for treatment of postoperative shivering and also noted that nefopam has no influence on the extubation time (25). In a study by Abdulameer AN et al., they observed that a single bolus dose of nefopam allows the cessation of shivering after surgery in 95% of patients with no recurrent episodes of muscle twitching, nausea, vomiting, sweating, or tachycardia (17). These findings were quite similar to present study results, where 90% of patients had cessation of shivering after nefopam bolus dose.

Mohamed SH found nefopam better than dexmedetomidine for control of intraoperative shivering with its rapid onset, higher response rate and less side-effect (26). Alfonsi P et al., showed that nefopam caused a minor increase in the core temperature by decreasing the shivering threshold and without affecting sweating and vasoconstriction threshold, thereby minimising the loss of heat (27). However, other drugs such as clonidine, meperidine, tramadol reduce both shivering and vascular threshold which leads to greater heat loss. Kranke P et al., on his meta-analysis on medication and dosing practices observed that prophylaxis against perioperative shivering should start with external warming and if not relieved then progress to pharmacological interventions, as pharmacological prophylaxis is not cost-effective (28). Very few studies were done earlier comparing nalbuphine and nefopam for postoperative shivering after LC under GA, so the present study could be an important source of information for clinical researchers.


In present study, sample size was small, and the temperature of intravenous fluids was not monitored.


Nefopam as compared to nalbuphine had earlier cessation of shivering, better response rate and less side-effects, thus nefopam should be preferred for management of postoperative shivering after LC under GA. Large sample studies are recommended to confirm present study findings.


Horn EP. Hypothermia-pathophysiology, prophylaxis and therapy. Anasthesiologic Intensivmedizin Notfallmedizin Schmerztherapie. 2002;37:409-28. [crossref][PubMed]
Kurz A, Sessler DI, Narzt E, Baker A, Lenhardt R, Huemer G, et al. Postoperative hemodynamic and thermoregulatory consequences of intraoperative core hypothermia. J Clin Anaesth. 1997;7(5):359-66. [crossref][PubMed]
Eberhart LH, Doderlein F, Eisenhardt G, Kranke P, Sessler DI, Torossian A, et al. Independent risk factors for postoperative shivering. Anaesth Analg. 2005;101:1849-57. [crossref][PubMed]
Abdallah MS. Treatment of postoperative shivering after laparoscopic cholecystectomy under general anaesthesia: A comparative clinical study. Al- Azhar Assiut Medical Journal. 2019;17:190-97. [crossref]
De Witte J, Sessler DI. Perioperative shivering: physiology and pharmacology. Anaesthesiology. 2002;96(2):467-84. [crossref][PubMed]
Ott DE. Laparoscopic hypothermia. J Laproendoscopic Surg. 1991;1(3):127. [crossref][PubMed]
Nasiri A, Akbari A, Sharifzade G, Derakhshan P. The effects of warmed intravenous fluids, combined warming (warmed intravenous fluids with humid-warm oxygen), and pethidine on the severity of shivering in general anaesthesia patients in the recovery room. Iranian Journal of Nursing and Midwifery Research. 2015;20:712-16. [crossref][PubMed]
Torossian A. Perioperative thermal management in children. Anaesthesiol Intensivmed Notfallmed Schmerzther. 2013;48:278-80. [crossref][PubMed]
Lenhardt R. The effect of anaesthesia on body temperature control. Front Biosci (Schol Ed). 2010;2:1145-54. [crossref][PubMed]
Gunion MW, Marchionne AM, Anderson TM. Use of the mixed agonist antagonist nalbuphine in opioid based analgesia. Acute Pain. 2004;6:29-39. [crossref]
Kurz A, Ikedat T, Sessler DI, Larson MD, Bjorksten AR, Dechert M, et al. Mepreidine decreases the shivering threshold twice as much as the vasoconstriction threshold. Anaesthesiology. 1997;86:1046-54. [crossref][PubMed]
Thomas SM, Pradhan A, Chauhan D. A randomised clinical trial to compare the efficacy of tramadol and Nalbuphine for treatment of shivering after spinal anaesthesia in patients posted for lower limb orthopaedic surgery. J Clin Diag Res. 2021;15(5):UC16-UC20. [crossref]
Nirala DK, Prakash J, Ram B, Kumar V, Bhattacharya PK, Priye S. Randomised double-blinded comparative study of intravenous Nalbuphine and Tramadol for the treatment of postspinal anaesthesia shivering. Anaesth Essays Res. 2020;14(3):510-14. [crossref][PubMed]
Rosland JH, Hole K. The effect of nefopam and its enantiomers on the uptake of 5-hydroxytryptamine, noradrenaline and dopamine in crude rat brain synaptosomal preparations. J Pharm Pharmacol. 1990;42(6):437-38. [crossref][PubMed]
Hocker J, Gruenewald M, Meybohm P, Schaper C, Scholz J, Steinfath M, et al. Nefopam but not physostigmine affects the thermoregulatory response in mice via alpha(2)-adrenoceptors. Neuropharmacology.2010;58(2):495-500. [crossref][PubMed]
Taneja P, Bansal Y, Sharma N, Banotra KK. A randomised control trial for comparision among nalbuphine, tramadol and placebo for treating post anaesthetic shivering undergoing spinal anaesthesia in cessarian section. Journal of Pharmaceutical Sciences and Research. 2019;11(5):2095-98.
Abdulameer AN, Mohamad NA, Saleh LM. Using nefopam for management of postoperative shivering. World Bulletin of Public Health. 2022;15:102-08.
Kaur H, Kaur S, Gupta KK, Singh A. Comparative evaluation of the intravenous dexmedetomidine and nalbuphine for treatment of post spinal shivering- A randomised prospective trial. Asian J Anaesthesiol. 2022;60(4):146-54.
Crossley AWA. Peri-operative shivering. Anaesth. 1992;47:193-95. [crossref][PubMed]
Crossley AWA, Mahajan RP. Intensity of postoperative shivering is unrelated to axillary temperature. Anaesth. 1994;49(3):205-07. [crossref][PubMed]
Buggy DJ, Crossley AWA. Thermoregulation, mild perioperative hypothermia and hypothermia and post-anaesthetic shivering. British J Anaesth. 2000;84(54):615-28. [crossref][PubMed]
Sessler DI. Temperature monitoring and perioperative thermoregulation. Anaesthesiol. 2008;109:318-38. [crossref][PubMed]
Matsota PK, Koliantzaki IK, Kostopanagiotou GG. Pharmacological approach for the prevention of postoperative shivering: A systematic review of prospective randomised controlled trials. Asian J Anaesthesiol. 2019;57(3):66-84.
Megalla SA, Mansour HS. Dexmedetomidine versus Nalbuphine for treatment of postspinal shivering in patients undergoing vaginal hysterectomy: A randomised, double blind, controlled study. Egyptian J Anaesth. 2016;33(1):47-52. [crossref]
Lv M, Wang X, Qu W, Liu M, Wang Y. Nefopam for the prevention of perioperative shivering: A meta-analysis of randomised controlled trials. BMC Anaesthesiol. 2015;15:87. [crossref][PubMed]
Mohamed SH. Dexmedetomidine versus Nefopam for the management of post-spinal anaesthesia shivering: A randomised double-blind controlled study. Egyptian J Anaesth. 2015;31(4):315-20. [crossref]
Alfonsi P, Adam F, Passard A, Guignard B, Sessler DI, Chauvin M. Nefopam, anonsedative benzoxazocine analgesic, selectively reduces the shivering threshold in unanaesthetized subjects. Anaesthesiology. 2004;100(1):37-43. [crossref][PubMed]
Kranke P, Eberhart LH, Roewer N, Tramer MR. Pharmacological treatment of postoperative shivering: A quantitative systematic review of randomised controlled trials. Anaesth Analg. 2002;94:453-60.[crossref]

DOI and Others

DOI: 10.7860/JCDR/2023/64038.18034

Date of Submission: Mar 12, 2023
Date of Peer Review: Apr 17, 2023
Date of Acceptance: May 22, 2023
Date of Publishing: Jun 01, 2023

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Mar 15, 2023
• Manual Googling: May 05, 2023
• iThenticate Software: May 16, 2023 (17%)

ETYMOLOGY: Author Origin


JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)