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(Stroke. 2008;39:3242.)
© 2008 American Heart Association, Inc.

Original Contributions

Metabolic Impact of Shivering During Therapeutic Temperature Modulation

The Bedside Shivering Assessment Scale

Neeraj Badjatia, MD, MSc; Evangelia Strongilis, RD; Errol Gordon, MD; Mary Prescutti, RN; Luis Fernandez, MD; Andres Fernandez, MD; Manuel Buitrago, MD, PhD; J. Michael Schmidt, PhD; Noeleen D. Ostapkovich, MSc Stephan A. Mayer, MD, FCCM

From the Departments of Neurology (N.B., E.G., L.F., A.F., M.B., J.M.S., N.D.O., S.A.M.) and Neurosurgery (N.B., S.A.M.), Columbia University College of Physicians and Surgeons, New York, NY; and the Departments of Clinical Nutrition (E.S.) and Nursing (M.P.), New York Presbyterian Hospital, New York, NY.

Correspondence to Neeraj Badjatia, MD, MSc, Milstein Hospital Building, 8 Garden Center, 177 Fort Washington Avenue, New York, NY 10032. E-mail nbadjatia{at}neuro.columbia.edu

Background and Purpose— Therapeutic temperature modulation is widely used in neurocritical care but commonly causes shivering, which can hamper the cooling process and result in increases in systemic metabolism. We sought to validate a grading scale to assist in the monitoring and control of shivering.

Methods— A simple 4-point Bedside Shivering Assessment Scale was validated against continuous assessments of resting energy expenditure, oxygen consumption, and carbon dioxide production as measured by indirect calorimetry. Therapeutic temperature modulation for fever control or the induction of hypothermia was achieved with the use of a surface or endovascular device. Expected energy expenditure was calculated using the Harris–Benedict equation. A hypermetabolic index was calculated from the ratio of resting of energy expenditure to energy expenditure.

Results— Fifty consecutive cerebrovascular patients underwent indirect calorimetry between January 2006 and June 2007. Fifty-six percent were women, and mean age 63±16 years. The majority underwent fever control (n=40 [80%]) with a surface cooling device (n=44 [87%]) and had signs of shivering (Bedside Shivering Assessment Scale >0, 64% [n=34 of 50]). Low serum magnesium was independently associated with the presence of shivering (Bedside Shivering Assessment Scale >0; OR, 6.8; 95% CI, 1.7 to 28.0; P=0.01). The Bedside Shivering Assessment Scale was independently associated with the hypermetabolic index (W=16.3, P<0.001), oxygen consumption (W=26.3, P<0.001), resting energy expenditure (W=27.2, P<0.001), and carbon dioxide production (W=18.2, P<0.001) with a high level of interobserver reliability (_w=0.84, 95% CI, 0.81 to 0.86).

Conclusion— The Bedside Shivering Assessment Scale is a simple and reliable tool for evaluating the metabolic stress of shivering.

Key Words: hypothermia • intracerebral hemorrhage • ischemic stroke • normothermia • shivering • subarachnoid hemorrhage