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A 60-year-old man with known coronary artery disease arrives in the postanesthesia care unit following an uneventful laparoscopic cholecystectomy. He is noted to be actively shivering, and his vital signs reveal the following:
Electrocardiography reveals ST segment elevation in the V5 lead. Administration of which of the following drugs is MOST appropriate as a next step in this patient’s management?
A. Hydralazine X
B. Metoprolol ✔
C. Meperidine X
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Shivering is a common postoperative complication that is usually related to hypothermia but can also occur in normothermic patients. Shivering produces energy that helps restore normothermia. However, in addition to causing patient discomfort, severe shivering can increase cardiac output and heart rate, leading to increased oxygen consumption in the heart. In susceptible patients, the increased heart rate can lead to a decreased diastolic time, decreased perfusion of the left ventricle, and myocardial ischemia. Therefore, controlling heart rate is a crucial first step in managing the potential myocardial ischemia.
In the clinical scenario, the patient has known coronary artery disease and presents with severe hypothermia, tachycardia, and hypertension. He is exhibiting signs of potential myocardial ischemia as evidenced by ST segment elevations on the electrocardiogram. While restoring normothermia is important (e.g., via a forced air warming blanket or warmed intravenous fluids), the best next step in managing this patient’s myocardial ischemia is heart rate control via a β-blocker such as metoprolol. This will quickly decrease myocardial oxygen demand and increase diastolic coronary artery perfusion time. A β-blocker will also help treat this patient’s severe hypertension. Other interventions may eventually be required for ongoing myocardial ischemia, but rapid heart rate control is an important early step in stabilizing the patient described in the scenario.
Other medications may be appropriate to treat the shivering, such as low-dose meperidine. However, in the scenario provided, a rapidly acting β-blocker should be administered first to quickly reestablish a normal heart rate, improve the patient’s myocardial oxygen supply, and lower the myocardial oxygen demand.
While hydralazine can be used to treat hypertension, it may worsen tachycardia and would not be the most appropriate choice in the provided scenario.
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Date of last update: March 25, 2026
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