Efficacy and safety of ketamine and esketamine for the prevention of postanesthetic shivering in cesarean delivery: a systematic review and meta-analysis

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Purpose Shivering is a common and undesirable complication associated with cesarean delivery under intrathecal anesthesia, which causes discomfort in patients and may interfere with vital signs monitoring. The main purpose of this meta-analysis was to evaluate the efficacy and safety of ketamine and esketamine for the prevention of postanesthetic shivering. Methods We performed a systematic search of PubMed, Embase, Web of Science, CENTRAL, CNKI, and Wan Fang databases for randomized controlled trials (RCTs) evaluating the efficacy of ketamine and esketamine in preventing shivering in women undergoing cesarean delivery. The primary outcomes of this analysis were the incidence and the severity of postanesthetic shivering. Secondary outcomes were the incidence of adverse events. We integrated traditional meta-analysis with logistic regression to establish the dose-response relationships. Results A total of 12 RCTs involving 1683 patients were included; most are assessed as low risk or with some concerns, and the quality of the evidence is mostly low and moderate. The incidence of postanesthetic shivering during cesarean delivery was significantly lower in the ketamine and esketamine (RR: 0.29; 95% CI: 0.20–0.42; P < 0.00001) groups than in the placebo group, particularly for grade 2–4 shivering. Multivariable meta-regression and logistic regression showed that the preventive efficacy of ketamine and esketamine against shivering was significantly correlated with dose. Ketamine and esketamine have an advantage in reducing the incidence of nausea and vomiting (RR: 0.52; 95% CI: 0.38–0.71; P < 0.0001), hypotension (RR: 0.36; 95% CI: 0.20–0.66; P = 0.001), and bradycardia (RR: 0.47; 95% CI: 0.30–0.73; P = 0.0009) compared with a placebo. However, the ketamine and esketamine groups exhibited significantly higher incidences of hallucination (RR: 11.19; 95% CI: 3.46–36.19; P < 0.0001) and nystagmus (RR: 10.58; 95% CI: 3.76–29.75; P < 0.00001) compared with the placebo group, and these adverse events are dose-dependent. Conclusion Prophylactic application of ketamine and esketamine could be efficacious for reducing postanesthetic shivering during cesarean delivery. However, the dose-dependent increases in hallucination and nystagmus highlight the need to balance preventive efficacy against psychiatric adverse events when selecting the optimal dose. Additional convincing evidence is required to prove their value and safety in preventing shivering for obstetric patients. Systematic review registration https://www.crd.york.ac.uk/prospero/ , identifier CRD420251076816.

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