Shivering is common during targeted temperature management and controlling it can be challenging if clinicians are not familiar with the available options and recommended approaches. The purpose of completing this review is to summarize the most relevant literature regarding various treatments available for shivering control and to recommend an approach based on the latest data. We queried a variety of electronic databases, such as PubMed/MEDLINE and Google Scholar, to identify studies that were systematically reviewed. Overall, non-pharmacologic methods were found to have a very low adverse effect profile and ease of use, but did not always fully control shivering. Pharmacologic methods can effectively control shivering, but some have adverse effects, such that risks and benefits to the patient must be balanced.
The review concludes with a treatment approach which suggests that treatment for shivering control in targeted temperature management should be initiated before the onset of therapeutic hypothermia or prior to any attempt at lowering patient core temperature. First line medications include acetaminophen, buspirone, and magnesium sulfate, ideally administered in combination with skin counterwarming. After that, interventions should be determined with the help of a shivering scale. Step-wise escalation can be implemented that balances treatment with sedation, aiming to provide the most shivering reduction with the least sedating medications and reserving paralytics for the last line of treatment.