Intrathecal Ketamine Added to Bupivacaine for Prevention of Post-Spinal Shivering in Elective Cesarean Delivery: A Double-Blind Randomized Clinical Trial
-
Alireza Shakeri
,
Arezou Ashari
,
Zahraa Hasan Mohammed Mohammed
,
Ebtehaj Heshmatkhah
,
Niloofar Khosravi
,
Dariush Abtahi
Abstract
Background: Post-spinal shivering is a common complication during cesarean delivery under spinal anesthesia, occurring in 30-50% of parturients. Shivering increases oxygen consumption, interferes with monitoring, and negatively impacts maternal satisfaction. Intrathecal ketamine, an NMDA receptor antagonist, may provide anti-shivering benefits while avoiding systemic side effects. The objective is to evaluate the efficacy and safety of intrathecal ketamine (0.1 mg/kg) combined with bupivacaine in reducing post-spinal shivering during elective cesarean sections.
Methods: This parallel-group, double-blind, randomized clinical trial enrolled 100 ASA II parturients undergoing elective cesarean section under spinal anesthesia. Patients were randomized to receive either intrathecal bupivacaine 12.5 mg plus ketamine 0.1 mg/kg (Group A, n=50) or bupivacaine 12.5 mg alone (Group B, n=50). Primary outcomes included shivering incidence and severity using the Bedside Shivering Assessment Scale. Secondary outcomes included block characteristics, time to the first analgesic request, and adverse events.
Results: Intraoperative shivering was significantly reduced in the ketamine group (10% vs. 40%; p<0.001; OR=0.167, 95% CI: 0.056–0.492), representing an 83% relative risk reduction. Time to first analgesic request was prolonged in Group A (145 vs. 125 minutes; p<0.001). Motor block duration, PONV incidence, and patient satisfaction were comparable between groups. No neurological complications were observed during the two-month follow-up.
Conclusion: Intrathecal ketamine (0.1 mg/kg) significantly reduces post-spinal shivering incidence and severity while prolonging postoperative analgesia without increasing adverse effects, representing an effective non-opioid adjuvant for obstetric spinal anesthesia.
[1] Ferede YA, Aytolign HA, Mersha AT. "The magnitude and associated factors of intraoperative shivering after cesarean section delivery under Spinal anesthesia'': A cross sectional study. Ann Med Surg (Lond). 2021; 72:103022.
[2] Kumar K, Lin C, Symons T, Railton C. Narrative Review on Perioperative Shivering during Caesarean Section under Neuraxial Anaesthesia. Rom J Anaesth Intensive Care. 2023; 29(1):41-6.
[3] Amsalu H, Zemedkun A, Regasa T, Adamu Y. Evidence-Based Guideline on Prevention and Management of Shivering After Spinal Anesthesia in Resource-Limited Settings: Review Article. Int J Gen Med. 2022; 15:6985-98.
[4] Kanchan S, Shah AM, Shah A, Sameen Z, Arya A, Riaz S, et al. Post spinal anaesthesia shivering- incidence and associated risk factors in patients undergoing lower limb and abdominal surgeries. Int J Res Med Sci. 2022; 10(10):2285-90.
[5] Wódarski B, Chutkowski R, Banasiewicz J, Moorthi K, Wójtowicz S, Malec-Milewska M, et al. Risk factors for shivering during caesarean section under spinal anaesthesia. A prospective observational study. Acta Anaesthesiol Scand. 2020; 64(1):112-6.
[6] Goich K, Pastore D, Koutsenko B, Infosino B, Sgrignoli MN, Schachter T. A Scoping Review: Ketamine for the Prevention of Perioperative Shivering in Patients Undergoing Spinal Anesthesia. Cureus. 2024; 16(8):e66630.
[7] Honarmand A, Safavi MR. Comparison of prophylactic use of midazolam, ketamine, and ketamine plus midazolam for prevention of shivering during regional anaesthesia: a randomized double-blind placebo controlled trial. Br J Anaesth. 2008; 101(4):557-62.
[8] Aboelsuod MAA, Elnaggar AMA, Alwafa TAAA, Ahmed MMH, Elbeltagy ASA, Elbarbary MIA. Effect of Intravenous Ketamine Infusion on Hemodynamics of Patients Undergoing Cesarean Delivery after Spinal Anaesthesia: A Randomized, Double-Blind, Controlled Trial. Turk J Anaesthesiol Reanim. 2023; 51(5):420-6.
[9] Sangi S, Mesbah Kiaei M, Aligholizadeh M, Babajani A, Akbarpour P, Sarkhosh M, et al. Mitigating Post-Spinal Anesthesia Shivering by Exploring Intravenous Ketamine vs. Intravenous Tramadol and Comparison of the Optimal Dose of Ketamine: A Scoping Review of Cohort and Randomized Controlled Trials Studies. Arch Anesth & Crit Care. 2024; 11(3):407-16.
[10] Fenta E, Kibret S, Hunie M, Tamire T, Fentie Y, Seid S, et al. The effects of intravenous tramadol vs. intravenous ketamine in the prevention of shivering during spinal anesthesia: A meta-analysis of randomized controlled trials. Front Med (Lausanne). 2022; 9:1011953.
[11] Hawksworth C, Serpell M. Intrathecal anesthesia with ketamine. Reg Anesth Pain Med. 1998; 23(3):283-8.
[12] Khezri MB, Tahaei E, Atlasbaf AH. Comparison of postoperative analgesic effect of intrathecal ketamine and fentanyl added to bupivacaine in patients undergoing cesarean section: a prospective randomized double-blind study. Middle East J Anaesthesiol. 2016; 23(4):427-36.
[13] Samy Abbas M, Hamdy Mohamed W, Abdallah Osman E, Talat Ahmed A, Mohamed Mahdy M. Analgesic Efficacy And Side Effects Of Three Different Doses Of Intrathecal Ketamine As An Adjuvant To Intrathecal Bupivacaine In Patients Undergoing Knee Arthroscopy: A Randomized Study. J Curr Med Res Pract. 2024; 9(2):57-66.
[14] Lema GF, Gebremedhn EG, Gebregzi AH, Desta YT, Kassa AA. Efficacy of intravenous tramadol and low-dose ketamine in the prevention of post-spinal anesthesia shivering following cesarean section: a double-blinded, randomized control trial. Int J Womens Health. 2017; 9:681-8.
[15] Badjatia N, Strongilis E, Gordon E, Prescutti M, Fernandez L, Fernandez A, et al. Metabolic impact of shivering during therapeutic temperature modulation: the Bedside Shivering Assessment Scale. Stroke. 2008; 39(12):3242-7.
[16] Afzal M, Lee A, Asad M, Ali A, Farrukh AM, Semakieh B, et al. The effect of intrathecal pethidine on post-spinal anesthesia shivering after cesarean section: a systematic review and meta-analysis. Ann Med Surg (Lond). 2024; 86(9):5461-70.
[17] Amjad A, Khalid U, Ashraf A, Tariq S, Ehsan A, Zaidi SIA, et al. Evaluating The Effectiveness of Nefopam Versus Tramadol in Treating Established Post-Spinal Anesthesia Shivering: A Systematic Review. PJMD. 2025; 14(2):486-95.
[18] Bi YH, Wu JM, Zhang YZ, Zhang RQ. Effect of Different Doses of Intrathecal Dexmedetomidine as an Adjuvant Combined With Hyperbaric Ropivacaine in Patients Undergoing Cesarean Section. Front Pharmacol. 2020; 11:342.
[19] Kumar R, Pangotra A, Verma V. Role of intrathecal nalbuphine on prevention of post spinal shivering after turp-a randomised control double blind study. J Evid Based MedHealthc. 2023; 10(02):1-5.
[20] Lv M, Wang X, Qu W, Liu M, Wang Y. Nefopam for the prevention of perioperative shivering: a meta-analysis of randomized controlled trials. BMC Anesthesiology. 2015; 15:87.
[21] Nair A, Dudhedia U, Rangaiah M, Panchawagh S. Efficacy of intravenous nalbuphine for managing post-anaesthesia shivering: A systematic review and meta-analysis of randomised controlled trials with trial sequential analysis. Indian J Anaesth. 2023; 67(10):853-65.
[22] Tohme J, Chehade J, Abou Zeid H, Mattar R, Naccache N, Jabbour K, et al. Prevention of shivering post spinal anesthesia: Ondansetron vs. Nefopam ‒ a prospective randomized controlled trial. Braz J Anesthesiol. 2025; 75(5):844650.
[23] Liang X, Chen M, Hong A, Gu Z, Jiang J, Chen Y, et al. Prophylactic efficacy of oral gabapentin on postoperative shivering: A meta-analysis of randomized controlled trials. Medicine (Baltimore). 2025; 104(10):e41421.
[24] Zhang Y, Xia F, Zhang W, Lv A. Prophylactic ondansetron for preventing intraoperative shivering, nausea and vomiting during spinal anesthesia for cesarean section: a randomized controlled trial. Front Pharmacol. 2024; 15:1500642.
[25] Chung SH, Lee BS, Yang HJ, Kweon KS, Kim HH, Song J, et al. Effect of preoperative warming during cesarean section under spinal anesthesia. Korean J Anesthesiol. 2012; 62(5):454-60.
[26] Rezaei M, Eidi M, Kolahdouzan K, Marahem M. Effectiveness of Dexmedetomidine Versus Meperidine in the treatment of shivering after general anesthesia. J Surg Trauma. 2024; 12(1):4-10.
[27] Xu Z, Tang Z, Yao J, Liang D, Jin F, Liu Y, et al. Comparison of low-dose morphine intrathecal analgesia and sufentanil PCIA in elderly patients with hip fracture undergoing single spinal anesthesia - a randomized clinical trial. BMC Anesthesiol. 2022; 22(1):124.
[28] Grape S, El-Boghdadly K, Albrecht E. Management of adverse effects of intrathecal opioids in acute pain. Best Pract Res Clin Anaesthesiol. 2023; 37(2):199-207.
[29] El-Boghdadly K, Renard Y, Rossel JB, Moka E, Volk T, Rawal N, et al. Pulmonary complications after intrathecal morphine administration: a systematic review and meta-analysis with meta-regression and trial sequential analysis. Anaesthesia. 2025; 80(8):959-72.
[30] Sohnen S, Dowling O, Shore-Lesserson L. Single dose perioperative intrathecal ketamine as an adjuvant to intrathecal bupivacaine: A systematic review and meta-analysis of adult human randomized controlled trials. J Clin Anesth. 2021; 73:110331.
[31] Kathirvel S, Sadhasivam S, Saxena A, Kannan TR, Ganjoo P. Effects of intrathecal ketamine added to bupivacaine for spinal anaesthesia. Anaesthesia. 2000; 55(9):899-904.
[32] Khezri MB, Ghasemi J, Mohammadi N. Evaluation of the analgesic effect of ketamine as an additive to intrathecal bupivacaine in patients undergoing cesarean section. Acta Anaesthesiol Taiwan. 2013; 51(4):155-60.
[33] Abd El Azeem EM, Abdel-Ghaffar ME, Al-Touny SA. Anti-shivering effect of intrathecal tramadol versus intravenous tramadol in patients Received spinal anesthesia for lower limb surgery. A randomized controlled clinical trial. Egypt J Anaesth. 2023; 39(1):50-5.
[34] Oluş F, Babun H. Sedation applications in pedodontics procedures: which one should we choose?: a retrospective analysis. BMC Oral Health. 2026; 26(1):363.
[35] Rivasi G, Menale S, Turrin G, Coscarelli A, Giordano A, Ungar A. The Effects of Pain and Analgesic Medications on Blood Pressure. Curr Hypertens Rep. 2022; 24(10):385-94.
[36] Alur J, Korikantimath VV, Jyoti B, Sushma KS, Mallayyagol NV. A Comparative Study of Analgesic Efficacy of Intrathecal Bupivacaine with Ketamine Versus Bupivacaine with Magnesium Sulphate in Parturients Undergoing Elective Caesarian Sections. Anesth Essays Res. 2021; 15(4):379-84.
[37] Seki H, Shiga T, Mihara T, Hoshijima H, Hosokawa Y, Hyuga S, et al. Effects of intrathecal opioids on cesarean section: a systematic review and Bayesian network meta-analysis of randomized controlled trials. J Anesth. 2021; 35(6):911-27.
[38] Malinovsky JM, Lepage JY, Cozian A, Mussini JM, Pinaudt M, Souron R. Is ketamine or its preservative responsible for neurotoxicity in the rabbit? Anesthesiology. 1993; 78(1):109-15.
[39] Errando CL, Sifre C, Moliner S, Valía JC, Gimeno O, Mínguez A, et al. Subarachnoid ketamine in swine--pathological findings after repeated doses: acute toxicity study. Reg Anesth Pain Med. 1999; 24(2):146-52.
[40] Borgbjerg FM, Svensson BA, Frigast C, Gordh T. Histopathology after repeated intrathecal injections of preservative-free ketamine in the rabbit: a light and electron microscopic examination. Anesth Analg. 1994; 79(6):1105-11.
[41] Stotz M, Oehen HP, Gerber H. Histological findings after long-term infusion of intrathecal ketamine for chronic pain: a case report. J Pain Symptom Manage. 1999; 18(3):223-8.
[42] Mahmoud MA, Fathi MK, Aladawy MA, Mostafa MI. Efficacy and Safety of Intrathecal Dexmedetomidine or Morphine as Adjuvant to Bupivacaine for Normal Labor Analgesia: A Randomized Clinical Study. Egypt J Hosp Med. 2025; 100:3095–101.
[43] van den Bosch OFC, Rijsdijk M, Rosier SE, van Baal L, Schaap TP, Sultan P, et al. The implementation of intrathecal morphine for caesarean delivery into clinical practice, and assessment of its impact on patient-reported quality of recovery using the ObsQoR-10-Dutch scale: A single-centre cohort study. Eur J Anaesthesiol. 2025; 42(4):332-9.
[2] Kumar K, Lin C, Symons T, Railton C. Narrative Review on Perioperative Shivering during Caesarean Section under Neuraxial Anaesthesia. Rom J Anaesth Intensive Care. 2023; 29(1):41-6.
[3] Amsalu H, Zemedkun A, Regasa T, Adamu Y. Evidence-Based Guideline on Prevention and Management of Shivering After Spinal Anesthesia in Resource-Limited Settings: Review Article. Int J Gen Med. 2022; 15:6985-98.
[4] Kanchan S, Shah AM, Shah A, Sameen Z, Arya A, Riaz S, et al. Post spinal anaesthesia shivering- incidence and associated risk factors in patients undergoing lower limb and abdominal surgeries. Int J Res Med Sci. 2022; 10(10):2285-90.
[5] Wódarski B, Chutkowski R, Banasiewicz J, Moorthi K, Wójtowicz S, Malec-Milewska M, et al. Risk factors for shivering during caesarean section under spinal anaesthesia. A prospective observational study. Acta Anaesthesiol Scand. 2020; 64(1):112-6.
[6] Goich K, Pastore D, Koutsenko B, Infosino B, Sgrignoli MN, Schachter T. A Scoping Review: Ketamine for the Prevention of Perioperative Shivering in Patients Undergoing Spinal Anesthesia. Cureus. 2024; 16(8):e66630.
[7] Honarmand A, Safavi MR. Comparison of prophylactic use of midazolam, ketamine, and ketamine plus midazolam for prevention of shivering during regional anaesthesia: a randomized double-blind placebo controlled trial. Br J Anaesth. 2008; 101(4):557-62.
[8] Aboelsuod MAA, Elnaggar AMA, Alwafa TAAA, Ahmed MMH, Elbeltagy ASA, Elbarbary MIA. Effect of Intravenous Ketamine Infusion on Hemodynamics of Patients Undergoing Cesarean Delivery after Spinal Anaesthesia: A Randomized, Double-Blind, Controlled Trial. Turk J Anaesthesiol Reanim. 2023; 51(5):420-6.
[9] Sangi S, Mesbah Kiaei M, Aligholizadeh M, Babajani A, Akbarpour P, Sarkhosh M, et al. Mitigating Post-Spinal Anesthesia Shivering by Exploring Intravenous Ketamine vs. Intravenous Tramadol and Comparison of the Optimal Dose of Ketamine: A Scoping Review of Cohort and Randomized Controlled Trials Studies. Arch Anesth & Crit Care. 2024; 11(3):407-16.
[10] Fenta E, Kibret S, Hunie M, Tamire T, Fentie Y, Seid S, et al. The effects of intravenous tramadol vs. intravenous ketamine in the prevention of shivering during spinal anesthesia: A meta-analysis of randomized controlled trials. Front Med (Lausanne). 2022; 9:1011953.
[11] Hawksworth C, Serpell M. Intrathecal anesthesia with ketamine. Reg Anesth Pain Med. 1998; 23(3):283-8.
[12] Khezri MB, Tahaei E, Atlasbaf AH. Comparison of postoperative analgesic effect of intrathecal ketamine and fentanyl added to bupivacaine in patients undergoing cesarean section: a prospective randomized double-blind study. Middle East J Anaesthesiol. 2016; 23(4):427-36.
[13] Samy Abbas M, Hamdy Mohamed W, Abdallah Osman E, Talat Ahmed A, Mohamed Mahdy M. Analgesic Efficacy And Side Effects Of Three Different Doses Of Intrathecal Ketamine As An Adjuvant To Intrathecal Bupivacaine In Patients Undergoing Knee Arthroscopy: A Randomized Study. J Curr Med Res Pract. 2024; 9(2):57-66.
[14] Lema GF, Gebremedhn EG, Gebregzi AH, Desta YT, Kassa AA. Efficacy of intravenous tramadol and low-dose ketamine in the prevention of post-spinal anesthesia shivering following cesarean section: a double-blinded, randomized control trial. Int J Womens Health. 2017; 9:681-8.
[15] Badjatia N, Strongilis E, Gordon E, Prescutti M, Fernandez L, Fernandez A, et al. Metabolic impact of shivering during therapeutic temperature modulation: the Bedside Shivering Assessment Scale. Stroke. 2008; 39(12):3242-7.
[16] Afzal M, Lee A, Asad M, Ali A, Farrukh AM, Semakieh B, et al. The effect of intrathecal pethidine on post-spinal anesthesia shivering after cesarean section: a systematic review and meta-analysis. Ann Med Surg (Lond). 2024; 86(9):5461-70.
[17] Amjad A, Khalid U, Ashraf A, Tariq S, Ehsan A, Zaidi SIA, et al. Evaluating The Effectiveness of Nefopam Versus Tramadol in Treating Established Post-Spinal Anesthesia Shivering: A Systematic Review. PJMD. 2025; 14(2):486-95.
[18] Bi YH, Wu JM, Zhang YZ, Zhang RQ. Effect of Different Doses of Intrathecal Dexmedetomidine as an Adjuvant Combined With Hyperbaric Ropivacaine in Patients Undergoing Cesarean Section. Front Pharmacol. 2020; 11:342.
[19] Kumar R, Pangotra A, Verma V. Role of intrathecal nalbuphine on prevention of post spinal shivering after turp-a randomised control double blind study. J Evid Based MedHealthc. 2023; 10(02):1-5.
[20] Lv M, Wang X, Qu W, Liu M, Wang Y. Nefopam for the prevention of perioperative shivering: a meta-analysis of randomized controlled trials. BMC Anesthesiology. 2015; 15:87.
[21] Nair A, Dudhedia U, Rangaiah M, Panchawagh S. Efficacy of intravenous nalbuphine for managing post-anaesthesia shivering: A systematic review and meta-analysis of randomised controlled trials with trial sequential analysis. Indian J Anaesth. 2023; 67(10):853-65.
[22] Tohme J, Chehade J, Abou Zeid H, Mattar R, Naccache N, Jabbour K, et al. Prevention of shivering post spinal anesthesia: Ondansetron vs. Nefopam ‒ a prospective randomized controlled trial. Braz J Anesthesiol. 2025; 75(5):844650.
[23] Liang X, Chen M, Hong A, Gu Z, Jiang J, Chen Y, et al. Prophylactic efficacy of oral gabapentin on postoperative shivering: A meta-analysis of randomized controlled trials. Medicine (Baltimore). 2025; 104(10):e41421.
[24] Zhang Y, Xia F, Zhang W, Lv A. Prophylactic ondansetron for preventing intraoperative shivering, nausea and vomiting during spinal anesthesia for cesarean section: a randomized controlled trial. Front Pharmacol. 2024; 15:1500642.
[25] Chung SH, Lee BS, Yang HJ, Kweon KS, Kim HH, Song J, et al. Effect of preoperative warming during cesarean section under spinal anesthesia. Korean J Anesthesiol. 2012; 62(5):454-60.
[26] Rezaei M, Eidi M, Kolahdouzan K, Marahem M. Effectiveness of Dexmedetomidine Versus Meperidine in the treatment of shivering after general anesthesia. J Surg Trauma. 2024; 12(1):4-10.
[27] Xu Z, Tang Z, Yao J, Liang D, Jin F, Liu Y, et al. Comparison of low-dose morphine intrathecal analgesia and sufentanil PCIA in elderly patients with hip fracture undergoing single spinal anesthesia - a randomized clinical trial. BMC Anesthesiol. 2022; 22(1):124.
[28] Grape S, El-Boghdadly K, Albrecht E. Management of adverse effects of intrathecal opioids in acute pain. Best Pract Res Clin Anaesthesiol. 2023; 37(2):199-207.
[29] El-Boghdadly K, Renard Y, Rossel JB, Moka E, Volk T, Rawal N, et al. Pulmonary complications after intrathecal morphine administration: a systematic review and meta-analysis with meta-regression and trial sequential analysis. Anaesthesia. 2025; 80(8):959-72.
[30] Sohnen S, Dowling O, Shore-Lesserson L. Single dose perioperative intrathecal ketamine as an adjuvant to intrathecal bupivacaine: A systematic review and meta-analysis of adult human randomized controlled trials. J Clin Anesth. 2021; 73:110331.
[31] Kathirvel S, Sadhasivam S, Saxena A, Kannan TR, Ganjoo P. Effects of intrathecal ketamine added to bupivacaine for spinal anaesthesia. Anaesthesia. 2000; 55(9):899-904.
[32] Khezri MB, Ghasemi J, Mohammadi N. Evaluation of the analgesic effect of ketamine as an additive to intrathecal bupivacaine in patients undergoing cesarean section. Acta Anaesthesiol Taiwan. 2013; 51(4):155-60.
[33] Abd El Azeem EM, Abdel-Ghaffar ME, Al-Touny SA. Anti-shivering effect of intrathecal tramadol versus intravenous tramadol in patients Received spinal anesthesia for lower limb surgery. A randomized controlled clinical trial. Egypt J Anaesth. 2023; 39(1):50-5.
[34] Oluş F, Babun H. Sedation applications in pedodontics procedures: which one should we choose?: a retrospective analysis. BMC Oral Health. 2026; 26(1):363.
[35] Rivasi G, Menale S, Turrin G, Coscarelli A, Giordano A, Ungar A. The Effects of Pain and Analgesic Medications on Blood Pressure. Curr Hypertens Rep. 2022; 24(10):385-94.
[36] Alur J, Korikantimath VV, Jyoti B, Sushma KS, Mallayyagol NV. A Comparative Study of Analgesic Efficacy of Intrathecal Bupivacaine with Ketamine Versus Bupivacaine with Magnesium Sulphate in Parturients Undergoing Elective Caesarian Sections. Anesth Essays Res. 2021; 15(4):379-84.
[37] Seki H, Shiga T, Mihara T, Hoshijima H, Hosokawa Y, Hyuga S, et al. Effects of intrathecal opioids on cesarean section: a systematic review and Bayesian network meta-analysis of randomized controlled trials. J Anesth. 2021; 35(6):911-27.
[38] Malinovsky JM, Lepage JY, Cozian A, Mussini JM, Pinaudt M, Souron R. Is ketamine or its preservative responsible for neurotoxicity in the rabbit? Anesthesiology. 1993; 78(1):109-15.
[39] Errando CL, Sifre C, Moliner S, Valía JC, Gimeno O, Mínguez A, et al. Subarachnoid ketamine in swine--pathological findings after repeated doses: acute toxicity study. Reg Anesth Pain Med. 1999; 24(2):146-52.
[40] Borgbjerg FM, Svensson BA, Frigast C, Gordh T. Histopathology after repeated intrathecal injections of preservative-free ketamine in the rabbit: a light and electron microscopic examination. Anesth Analg. 1994; 79(6):1105-11.
[41] Stotz M, Oehen HP, Gerber H. Histological findings after long-term infusion of intrathecal ketamine for chronic pain: a case report. J Pain Symptom Manage. 1999; 18(3):223-8.
[42] Mahmoud MA, Fathi MK, Aladawy MA, Mostafa MI. Efficacy and Safety of Intrathecal Dexmedetomidine or Morphine as Adjuvant to Bupivacaine for Normal Labor Analgesia: A Randomized Clinical Study. Egypt J Hosp Med. 2025; 100:3095–101.
[43] van den Bosch OFC, Rijsdijk M, Rosier SE, van Baal L, Schaap TP, Sultan P, et al. The implementation of intrathecal morphine for caesarean delivery into clinical practice, and assessment of its impact on patient-reported quality of recovery using the ObsQoR-10-Dutch scale: A single-centre cohort study. Eur J Anaesthesiol. 2025; 42(4):332-9.
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How to Cite
1.
Shakeri A, Ashari A, Mohammed ZHM, Heshmatkhah E, Khosravi N, Abtahi D. Intrathecal Ketamine Added to Bupivacaine for Prevention of Post-Spinal Shivering in Elective Cesarean Delivery: A Double-Blind Randomized Clinical Trial. Arch Anesth & Crit Care. 2026;.
