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Effect of Shivering on Brain Tissue Oxygenation During Induced Normothermia in Patients With Severe Brain Injury



We analyzed the impact of shivering on brain tissue oxygenation (PbtO2) during induced normothermia in patients with severe brain injury.


We studied patients with severe brain injury who developed shivering during induced normothermia. Induced normothermia was applied to treat refractory fever (body temperature [BT] ≥38.3°C, refractory to conventional treatment) using a surface cooling device with computerized adjustment of patient BT target to 37 ± 0.5°C. PbtO2, intracranial pressure, mean arterial pressure, cerebral perfusion pressure, and BT were monitored continuously. Circulating water temperature of the device system was measured to assess the intensity of cooling.


Fifteen patients (10 with severe traumatic brain injury, 5 with aneurysmal subarachnoid hemorrhage) were treated with induced normothermia for an average of 5 ± 2 days. Shivering caused a significant decrease in PbtO2 levels both in SAH and TBI patients. Compared to baseline, shivering was associated with an overall reduction of PbtO2 from 34.1 ± 7.3 to 24.4 ± 5.5 mmHg (P < 0.001). A significant correlation was found between the magnitude of shivering-associated decrease of PbtO2 (ΔPbtO2) and circulating water temperature (R = 0.82, P < 0.001).


In patients with severe brain injury treated with induced normothermia, shivering was associated with a significant decrease of PbtO2, which correlated with the intensity of cooling. Monitoring of therapeutic cooling with computerized thermoregulatory systems may help prevent shivering and optimize the management of induced normothermia. The clinical significance of shivering-induced decrease in brain tissue oxygenation remains to be determined.

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We wish to thank Professor Patrick D. Lyden, MD, Chairman, Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, for the careful and helpful review of the manuscript and Prof. Scott E. Kasner, MD, Director, Comprehensive Stroke Center, Department of Neurology, University of Pennsylvania Medical Center, Philadelphia, PA, for statistical assistance. This work was supported by Research Grants from the SICPA Foundation, Switzerland (MO), the Integra Foundation (PDLR), and the Mary Elisabeth Groff Surgical and Medical Research Trust (PDLR).

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Correspondence to Joshua M. Levine.

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This work was performed in the Neurointensive Care Unit, Hospital of the University of Pennsylvania, Philadelphia, PA.

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Oddo, M., Frangos, S., Maloney-Wilensky, E. et al. Effect of Shivering on Brain Tissue Oxygenation During Induced Normothermia in Patients With Severe Brain Injury. Neurocrit Care 12, 10–16 (2010).

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  • Induced normothermia
  • Fever control
  • Temperature management
  • Surface cooling
  • Shivering
  • Brain tissue oxygenation
  • Brain injury
  • SAH
  • TBI
  • Neurointensive care
  • Neurocritical care