Effect of Prewarming On Skin Temperature Changes

Spinal Anesthesia Clinical Trial

Official title:

Effect of Prewarming On Skin Temperature Changes After Spinal Anesthesia in Transurethral Resection of The Bladder

Clinical Trial Details — Status: Not yet recruiting

Administrative data

• NCT number: NCT05063292
• Other study ID #: NeginIzmirBozyaka
• Status: Not yet recruiting
• Phase: N/A
• Start date: October 5, 2021
• Est. completion date: November 18, 2021

Study information

• Verified date: September 2021
• Source: Bozyaka Training and Research Hospital
• Contact: Negin Nayebi, MD
• Phone: +905541491707
• Email: negin.naebi[@]gmail.com
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

In this randomized prospective single-blind study,American Society of Anesthesiologists physical status classification system ( ASA )I-II-III patients aged 50-80 years undergoing transurethral bladder resection will be randomly divided into two groups. First group will be covered with 41 centigrade degrees double layered cotton cloth. Second group will receive active prewarming. Core temperature of all patients will be monitorized via tympanic membrane. Skin temperature will be monitorized from 4 different body areas. Spinal anesthesia will be applied at the level of L3-L4 by a 25 Gauge quincke needle with a dose of 12.5-15 mg hyperbaric bupivacaine. Pinprick test will be used for sensorial block assessment. T10 sensorial block will be our goal. Hemodynamic parameters will be recorded. Skin temperature will be monitorized before and after spinal anesthesia and changes will be recorded. Operation time, amount and temperature of irrigation fluids, transfusion requirement, discharge time from postoperative care unit will also be recorded. Shivering score and thermal comfort scale will be used. The two groups will be compared for the temperature changes.

Description:

In this prospective single-blind study, patients will be divided into 2 groups with computer-based randomization technique. All patients will have a fasting time of 2 hours for clear fluid and 6 hours for solid food. Patients will be taken to the premedication room before the operation. Written and verbal approval will be taken from all patients. Tympanic membrane will be used for core temperature measurement by Citizen ear thermometer,every 15 minutes.Adult skin temperature probe will be used for continuous peripheral temperature measurement from four different body areas (T1:Cervical7 (C7) dermatome, T2:C6 dermatome T3:Lumbar 5( L5 )dermatome, T4: L4 dermatome). The two groups will have an infusion of balanced electrolyte solution with a rate of 8 Mililitre/Kilogram/ hour(mL/kg/hour). Patients in Group I will be covered with a 41 centigrade degrees double layered cotton clothes. Patients in Group II will receive active prewarming with a forced-air warming blanket (WarmCare full body blanket) 30 minutes prior to the operation. 0.1 mg/kg intravenous (iv) midazolam hydrochloride will be administered for premedication. Patients will be transferred to operating room, covered with warmed double layered cotton clothes. Standard monitoring (pulse oximetry, noninvasive blood pressure, electrocardiography) will be applied to the patients. Core temperature and 4-points skin temperature measurements will be recorded. Patients will be delivered 2 Liter/minute oxygen with a nasal cannula. Iv hydration will be continued by room temperature balanced electrolyte solution with an infusion rate of 2mililiter/kilogram/hour. Spinal anesthesia will be applied at the level of L3-L4 by a 25 Gauge Quincke needle with a dose of 12.5-15 mg hyperbaric bupivacaine in the sitting position. Then patients will be taken supine position. Hemodynamic measurements will be continued. Core temperature measurements will be done every 15 minutes. Peripheral skin temperature measurements will be continuous. 1st, 2nd ,3rd,4th ,5th ,6th, 7th, 8th, 9th and 10th minutes and every 5 minutes measurements will be recorded during the operation. Pinprick test will be used for sensorial block assessment. T10 sensorial block will be our goal. The time for adequate sensorial block (T10) will be recorded. The patients will be repositioned (lithotomy) before the beginning of surgery. 5 mg iv ephedrine and 0.5 mg iv atropine will be administered when the blood pressure will be %80 of the baseline pressure and heart rate. Operating time, amount and temperature of irrigation fluids, transfusion requirement will be recorded. All patients will be transferred to post anesthesia care unit (PACU). Core temperature measurements will be continued every 15 minutes at PACU. Shivering scale and thermal comfort scale will be used during and after the operation. 25 mg iv meperidine will be administered when the patient's shivering score will be more than 3. Length of PACU stay will be recorded.

Recruitment information / eligibility

• Status: Not yet recruiting
• Enrollment: 60
• Est. completion date: November 18, 2021
• Est. primary completion date: November 10, 2021
• Accepts healthy volunteers: No
• Gender: Male
• Age group: 50 Years to 80 Years

Eligibility

Inclusion Criteria:

• ASA I-II-III

• 50-80 years old

• Patients scheduled for transurethral baldder resection

Exclusion Criteria:

• Female gender

• Uncoordinated patients

• Have coagulopathy,

• Known allergies to drugs to be used,

• Patients diagnosed with severe hypovolemia

• Skin infection at the injection site.

• Body mass index greater than 35m2/kg

• patients with severe endocrinological disease

• Patients with cardiovascular diseases

• patients with severe aortic stenosis or severe mitral stenosis

• patients with increased intracranial pressure

Related Conditions & MeSH terms

• Core Temperature
• Hypothermia
• Hypothermia Following Anesthesia
• Prewarming
• Spinal Anesthesia
• Urologic Neoplasms
• Urological Cancer

Intervention

Procedure:
• Patients in Group II will receive active prewarming with an air forced blanket (full body blanket) 30 minutes prior to the operation
Core temperature and 4-points skin temperatures measurements will be recorded all over the operation. Patients will be delivered 2 Litre/minute oxygen with a nasal cannula.Iv hydration will be continued by room temperatured balanced electrolyte solution with an infusion rate of 2mL/kg/hr. Spinal anesthesia will be applied at the level of L3-L4 by a 25 Gauge Quincke needle with a dose of 12.5-15 mg hyperbaric bupivacaine in the sitting position.

Locations

Country	Name	City	State
Turkey	Bozyaka Training and Research Hospital	Izmir	Karabaglar

Sponsors (1)

Lead Sponsor	Collaborator
Bozyaka Training and Research Hospital

Country where clinical trial is conducted

Turkey, 

References & Publications (5)

Fradkin AJ, Zazryn TR, Smoliga JM. Effects of warming-up on physical performance: a systematic review with meta-analysis. J Strength Cond Res. 2010 Jan;24(1):140-8. doi: 10.1519/JSC.0b013e3181c643a0. Review. — View Citation

Frank SM, El-Rahmany HK, Tran KM, Vu B, Raja SN. Comparison of lower extremity cutaneous temperature changes in patients receiving lumbar sympathetic ganglion blocks versus epidural anesthesia. J Clin Anesth. 2000 Nov;12(7):525-30. — View Citation

Hermanns H, Werdehausen R, Hollmann MW, Stevens MF. Assessment of skin temperature during regional anaesthesia-What the anaesthesiologist should know. Acta Anaesthesiol Scand. 2018 Oct;62(9):1280-1289. doi: 10.1111/aas.13176. Epub 2018 Jun 25. Review. — View Citation

Jo YY, Chang YJ, Kim YB, Lee S, Kwak HJ. Effect of Preoperative Forced-Air Warming on Hypothermia in Elderly Patients Undergoing Transurethral Resection of the Prostate. Urol J. 2015 Nov 14;12(5):2366-70. — View Citation

Jun JH, Chung MH, Kim EM, Jun IJ, Kim JH, Hyeon JS, Lee MH, Lee HS, Choi EM. Effect of pre-warming on perioperative hypothermia during holmium laser enucleation of the prostate under spinal anesthesia: a prospective randomized controlled trial. BMC Anesthesiol. 2018 Dec 22;18(1):201. doi: 10.1186/s12871-018-0668-4. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	peripheral skin temperature at ( F0)	F0 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	just after spinal anesthesia done
Primary	peripheral skin temperature at( S0)	S0 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	just after spinal anesthesia done
Primary	peripheral skin temperature( T0)	T0 will be defined as temperature which measured at L5 dermatome plantar side of 1st toe with adult skin probe	just after spinal anesthesia done
Primary	peripheral skin temperature( M0)	M0 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	just after spinal anesthesia done
Primary	peripheral skin temperature( F1)	F1will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	60 seconds after spinal anesthesia done
Primary	peripheral skin temperature( F2)	F2 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	120 seconds after spinal anesthesia done
Primary	peripheral skin temperature( F3)	F3 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	180 seconds after spinal anesthesia done
Primary	peripheral skin temperature( F4)	F4 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	4 minute after spinal anesthesia done
Primary	peripheral skin temperature( F5)	F5 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	5 minute after spinal anesthesia done
Primary	peripheral skin temperature( F6)	F6 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	6 minute after spinal anesthesia done
Primary	peripheral skin temperature( F7)	F7 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	7 minute after spinal anesthesia done
Primary	peripheral skin temperature( F8)	F8 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	8 minute after spinal anesthesia done
Primary	peripheral skin temperature( F9)	F9 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	9 minute after spinal anesthesia done
Primary	peripheral skin temperature( F10)	F10 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	10 minute after spinal anesthesia done
Primary	peripheral skin temperature( F15)	F15 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	15 minute after spinal anesthesia done
Primary	peripheral skin temperature( F20)	F20 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	20 minute after spinal anesthesia done
Primary	peripheral skin temperature( F25)	F25 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	25 minute after spinal anesthesia done
Primary	peripheral skin temperature( F30)	F30 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	30 minute after spinal anesthesia done
Primary	peripheral skin temperature( F35)	F35 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	35 minute after spinal anesthesia done
Primary	peripheral skin temperature( F40)	F40 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	40 minute after spinal anesthesia done
Primary	peripheral skin temperature( F45)	F45 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	45 minute after spinal anesthesia done
Primary	peripheral skin temperature( F50)	F50 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	50 minute after spinal anesthesia done
Primary	peripheral skin temperature( F55)	F55 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	55 minute after spinal anesthesia done
Primary	peripheral skin temperature( F60)	F60 will be defined as temperature which measured at C7 dermatome from palmar side of the 3rd finger with adult skin probe	60 minute after spinal anesthesia done
Primary	peripheral skin temperature at( S1)	S1 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	60 seconds after spinal anesthesia done
Primary	peripheral skin temperature at( S2)	S2 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	120 seconds after spinal anesthesia done
Primary	peripheral skin temperature at( S3)	S3 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	180 seconds after spinal anesthesia done
Primary	peripheral skin temperature at( S4)	S4 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	4 minute after spinal anesthesia done
Primary	peripheral skin temperature at( S5)	S5 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	5 minute after spinal anesthesia done
Primary	peripheral skin temperature at( S6)	S6 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	6 minute after spinal anesthesia done
Primary	peripheral skin temperature at( S7)	S7 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	7 minute after spinal anesthesia done
Primary	peripheral skin temperature at( S8)	S8 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	8 minute after spinal anesthesia done
Primary	peripheral skin temperature at( S9)	S9 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	9 minute after spinal anesthesia done
Primary	peripheral skin temperature at( S10)	S10 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	10 minute after spinal anesthesia done
Primary	peripheral skin temperature at( S15)	S15 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	15 minute after spinal anesthesia done
Primary	peripheral skin temperature at( S20)	S20 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	20 minute after spinal anesthesia done
Primary	peripheral skin temperature at( S25)	S25 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	25 minute after spinal anesthesia done
Primary	peripheral skin temperature at( S30)	S30 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	30 minute after spinal anesthesia done
Primary	peripheral skin temperature at( S35)	S35 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	35 minute after spinal anesthesia done
Primary	peripheral skin temperature at( S40)	S40 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	40 minute after spinal anesthesia done
Primary	peripheral skin temperature at( S45)	S45 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	45 minute after spinal anesthesia done
Primary	peripheral skin temperature at( S50)	S50 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	50 minute after spinal anesthesia done
Primary	peripheral skin temperature at( S55)	S55 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	55 minute after spinal anesthesia done
Primary	peripheral skin temperature at( S60)	S60 will be defined as temperature which measured at C6 dermatome from ventral side of styloid process with adult skin probe	60 minute after spinal anesthesia done
Primary	peripheral skin temperature( T1)	T1 will be defined as temperature which measured at L5 dermatome plantar side of 1st toe with adult skin probe	60 seconds after spinal anesthesia done
Primary	peripheral skin temperature( T2)	T2 will be defined as temperature which measured at L5 dermatome plantar side of 1st toe with adult skin probe	120 seconds after spinal anesthesia done
Primary	peripheral skin temperature( T3)	T3 will be defined as temperature which measured at L5 dermatome plantar side of 1st toe with adult skin probe	180 seconds after spinal anesthesia done
Primary	peripheral skin temperature( T4)	T4 will be defined as temperature which measured at L5 dermatome plantar side of 1st toe with adult skin probe	4 minute after spinal anesthesia done
Primary	peripheral skin temperature( T5)	T5 will be defined as temperature which measured at L5 dermatome plantar side of 1st toe with adult skin probe	5 minute after spinal anesthesia done
Primary	peripheral skin temperature( T6)	T6 will be defined as temperature which measured at L5 dermatome plantar side of 1st toe with adult skin probe	6 minute after spinal anesthesia done
Primary	peripheral skin temperature( T7)	T7 will be defined as temperature which measured at L5 deramatome plantar side of 1st toe with adult skin probe	7 minute after spinal anesthesia done
Primary	peripheral skin temperature( T8)	T8 will be defined as temperature which measured at L5 dermatome plantar side of 1st toe with adult skin probe	8 minute after spinal anesthesia done
Primary	peripheral skin temperature( T9)	T9 will be defined as temperature which measured at L5 dermatome plantar side of 1st toe with adult skin probe	9 minute after spinal anesthesia done
Primary	peripheral skin temperature( T10)	T10 will be defined as temperature which measured at L5 dermatome plantar side of 1st toe with adult skin probe	10 minute after spinal anesthesia done
Primary	peripheral skin temperature( T15)	T15 will be defined as temperature which measured at L5 dermatome plantar side of 1st toe with adult skin probe	15 minute after spinal anesthesia done
Primary	peripheral skin temperature( T20)	T20 will be defined as temperature which measured at L5 dermatome plantar side of 1st toe with adult skin probe	20 minute after spinal anesthesia done
Primary	peripheral skin temperature( T25)	T25 will be defined as temperature which measured L5 dermatome at plantar side of 1st toe with adult skin probe	25 minute after spinal anesthesia done
Primary	peripheral skin temperature( T30)	T30 will be defined as temperature which measured at L5 dermatome plantar side of 1st toe with adult skin probe	30 minute after spinal anesthesia done
Primary	peripheral skin temperature( T35)	T35 will be defined as temperature which measured at L5 dermatome plantar side of 1st toe with adult skin probe	35 minute after spinal anesthesia done
Primary	peripheral skin temperature( T40)	T40 will be defined as temperature which measured at L5 dermatome plantar side of 1st toe with adult skin probe	40 minute after spinal anesthesia done
Primary	peripheral skin temperature( T45)	T45will be defined as temperature which measured at L5 dermatome plantar side of 1st toe with adult skin probe	45 minute after spinal anesthesia done
Primary	peripheral skin temperature( T50)	T50 will be defined as temperature which measured at L5 dermatome plantar side of 1st toe with adult skin probe	50 minute after spinal anesthesia done
Primary	peripheral skin temperature( T55)	T55 will be defined as temperature which measured at L5 dermatome plantar side of 1st toe with adult skin probe	55 minute after spinal anesthesia done
Primary	peripheral skin temperature( T60)	T60 will be defined as temperature which measured at L5 dermatome plantar side of 1st toe with adult skin probe	60 minute after spinal anesthesia done
Primary	peripheral skin temperature( M1)	M1 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	60 seconds after spinal anesthesia done
Primary	peripheral skin temperature( M2)	M2 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	120 seconds after spinal anesthesia done
Primary	peripheral skin temperature( M3)	M3 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	180 seconds after spinal anesthesia done
Primary	peripheral skin temperature( M4)	M4 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	4 minute after spinal anesthesia done
Primary	peripheral skin temperature( M5)	M5 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	5 minute after spinal anesthesia done
Primary	peripheral skin temperature( M6)	M6 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	6 minute after spinal anesthesia done
Primary	peripheral skin temperature( M7)	M7 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	7 minute after spinal anesthesia done
Primary	peripheral skin temperature( M8)	M8 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	8 minute after spinal anesthesia done
Primary	peripheral skin temperature( M9)	M9 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	9 minute after spinal anesthesia done
Primary	peripheral skin temperature( M10)	M10 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	10 minute after spinal anesthesia done
Primary	peripheral skin temperature( M15)	M15 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	15 minute after spinal anesthesia done
Primary	peripheral skin temperature( M20)	M20 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	20 minute after spinal anesthesia done
Primary	peripheral skin temperature( M25)	M25 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	25 minute after spinal anesthesia done
Primary	peripheral skin temperature( M30)	M30 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	30 minute after spinal anesthesia done
Primary	peripheral skin temperature( M35)	M35 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	35 minute after spinal anesthesia done
Primary	peripheral skin temperature( M40)	M40 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	40 minute after spinal anesthesia done
Primary	peripheral skin temperature( M45)	M45 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	45 minute after spinal anesthesia done
Primary	peripheral skin temperature( M50)	M50 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	50 minute after spinal anesthesia done
Primary	peripheral skin temperature( M55)	M55 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	55 minute after spinal anesthesia done
Primary	peripheral skin temperature( M60)	M60 will be defined as temperature which measured at L4 dermatome above the medial malleolus with adult skin probe	60 minute after spinal anesthesia done
Secondary	core tympanic membrane temperature (C0)	centigrade degree , Timpanic membrane will be used for core temperature measurement by Citizen ear thermometer, CTD504,	just before spinal anesthesia done
Secondary	core tympanic membrane temperature(C1)	centigrade degree , Tympanic membrane will be used for core temperature measurement by Citizen ear thermometer, CTD504,	15 minute after spinal anesthesia done
Secondary	core tympanic membrane temperature(C2)	centigrade degree , Tympanic membrane will be used for core temperature measurement by Citizen ear thermometer, CTD504,	30 minute after spinal anesthesia done
Secondary	core tympanic membrane temperature(C3)	centigrade degree , Tympanic membrane will be used for core temperature measurement by Citizen ear thermometer, CTD504,	45 minute after spinal anesthesia done
Secondary	core tympanic membrane temperature(C4)	centigrade degree , Tympanic membrane will be used for core temperature measurement by Citizen ear thermometer, CTD504,	60 minute after spinal anesthesia done
Secondary	thermal comfort scale	thermal comfort will be rated on a 100mm visual analog scale (VAS),with zero indicating intense cold and 100mm representing intense heat	Immediately after the surgery
Secondary	shivering score(h0)	0: no shivering 1:piloerection or peripheral vasoconstriction but no visible shivering 2: muscular activity in only one muscle group 3:muscular activity in more then one muscle group but not generalized shivering 4:shivering involving the whole body	just before spinal anesthesia done
Secondary	shivering score(h1)	0: no shivering 1:piloerection or peripheral vasoconstriction but no visible shivering 2: muscular activity in only one muscle group 3:muscular activity in more then one muscle group but not generalized shivering 4:shivering involving the whole body	15 minute after spinal anesthesia done
Secondary	shivering score(h2)	0: no shivering 1:piloerection or peripheral vasoconstriction but no visible shivering 2: muscular activity in only one muscle group 3:muscular activity in more then one muscle group but not generalized shivering 4:shivering involving the whole body	30 minute after spinal anesthesia done
Secondary	shivering score(h3)	0: no shivering 1:piloerection or peripheral vasoconstriction but no visible shivering 2: muscular activity in only one muscle group 3:muscular activity in more then one muscle group but not generalized shivering 4:shivering involving the whole body	45 minute after spinal anesthesia done
Secondary	shivering score(h4)	0: no shivering 1:piloerection or peripheral vasoconstriction but no visible shivering 2: muscular activity in only one muscle group 3:muscular activity in more then one muscle group but not generalized shivering 4:shivering involving the whole body	60 minute after spinal anesthesia done
Secondary	shivering score(h5)	0: no shivering 1:piloerection or peripheral vasoconstriction but no visible shivering 2: muscular activity in only one muscle group 3:muscular activity in more then one muscle group but not generalized shivering 4:shivering involving the whole body	75 minute after spinal anesthesia done
Secondary	shivering score(h6)	0: no shivering 1:piloerection or peripheral vasoconstriction but no visible shivering 2: muscular activity in only one muscle group 3:muscular activity in more then one muscle group but not generalized shivering 4:shivering involving the whole body	90 minute after spinal anesthesia done
Secondary	shivering score(h7)	0: no shivering 1:piloerection or peripheral vasoconstriction but no visible shivering 2: muscular activity in only one muscle group 3:muscular activity in more then one muscle group but not generalized shivering 4:shivering involving the whole body	105 minute after spinal anesthesia done
Secondary	shivering score(h8)	0: no shivering 1:piloerection or peripheral vasoconstriction but no visible shivering 2: muscular activity in only one muscle group 3:muscular activity in more then one muscle group but not generalized shivering 4:shivering involving the whole body	120 minute after spinal anesthesia done