Skip to main content

Shivering: scores and protocols

Shivering is both an anticipated consequence and, potentially, a major adverse effect of therapeutic hypothermia. Even mild hypothermia can elicit a vigorous thermoregulatory defense to maintain body temperature at the hypothalamic set point. In healthy humans, peripheral vasoconstriction is triggered at 36.5°C and shivering at 35.5°C. Temperature thresholds for vasoconstriction and shivering are often higher than normal in brain-injured patients; therefore, these thermoregulatory defenses may occur more vigorously and at higher temperatures in these individuals. Control of shivering is essential for effective cooling, as shivering fights the cooling process, makes attaining target temperature difficult, is extremely uncomfortable, and can trigger massive increases in systemic and cerebral energy consumption and metabolic demand. The first step in treatment is adequate tools to recognize shivering. The Bedside Shivering Assessment Scale is a simple, validated four-point scale that enables repeated quantification of shivering at the bedside. Therapy for shivering should ideally stop or suppress the central thermoregulatory reflex rather than just uncoupling this response from skeletal muscle contraction, as the latter approach does not mitigate the ongoing cerebral and systemic stress response. Analgo-sedation with opioids, α2-receptor agonists, or propofol is almost always effective as a last resort to prevent shivering. However, nonpharmacological strategies as first-line interventions for shivering minimize the risk of excessive sedation, which can make neurological examination difficult and increase the risk of complications. The Columbia Anti Shivering protocol has been developed with these strategies in mind, and we base our approach on prospectively collected cooling data on 213 patients who underwent 1,388 patient-days of temperature modulation. Eighty-nine patients underwent hypothermia and 124 patients underwent induced normothermia. In 18% of patients and 33% of the total patient-days, only none-sedating baseline interventions were needed. The first agent used was most commonly dexmeditomidine half the time, followed by opiates and increased doses of propofol. Younger patients, men, and lower body surface area were factors associated with increased number of anti-shivering interventions. As noted by this protocol, a significant proportion of patients undergoing temperature modulation can be effectively treated for shivering without oversedation and paralysis. Patients at higher risk for needing more interventions are younger men with decreased body surface area.


  1. Choi HA, Badjatia N, Mayer SA: Hypothermia for acute brain injury-mechanisms and practical aspects. Nat Rev Neurol. 2012, doi: 10.1038/nrneurol.2012.21,

    Google Scholar 

  2. Choi HA, Ko SB, Presciutti M, Fernandez L, Carpenter AM, Lesch C, Gilmore E, Malhotra R, Mayer SA, Lee K, Claassen J, Schmidt JM, Badjatia N: Prevention of shivering during therapeutic temperature modulation: the Columbia anti-shivering protocol. Neurocrit Care. 2011, 14: 389-394. 10.1007/s12028-010-9474-7.

    Article  PubMed  Google Scholar 

  3. Badjatia N: Hyperthermia and fever control in brain injury [review]. Crit Care Med. 2009, 37 (7 Suppl): S250-S257.

    Article  PubMed  Google Scholar 

  4. Badjatia N, Strongilis E, Prescutti M, Fernandez L, Fernandez A, Buitrago M, Schmidt JM, Mayer SA: Metabolic benefits of surface counter warming during therapeutic temperature modulation. Crit Care Med. 2009, 37: 1893-1897. 10.1097/CCM.0b013e31819fffd3.

    Article  PubMed  Google Scholar 

  5. Badjatia N, Strongilis E, Gordon E, Prescutti M, Fernandez L, Fernandez A, Buitrago M, Schmidt JM, Ostapkovich ND, Mayer SA: Metabolic impact of shivering during therapeutic temperature modulation: the Bedside Shivering Assessment Scale. Stroke. 2008, 39: 3242-3247. 10.1161/STROKEAHA.108.523654.

    Article  PubMed  Google Scholar 

  6. Badjatia N, Kowalski RG, Schmidt JM, Voorhees ME, Claassen J, Ostapkovich ND, Presciutti M, Connolly ES, Palestrant D, Parra A, Mayer SA: Predictors and clinical implications of shivering during therapeutic normothermia. Neurocrit Care. 2007, 6: 186-191. 10.1007/s12028-007-0011-2.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations


Rights and permissions

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Cite this article

Badjatia, N. Shivering: scores and protocols. Crit Care 16 (Suppl 2), A9 (2012).

Download citation

  • Published:

  • DOI:


  • Body Surface Area
  • Therapeutic Hypothermia
  • Mild Hypothermia
  • Effective Cool
  • Peripheral Vasoconstriction