Dear Editor, We sincerely thank the reviewers for their thoughtful critique and valuable suggestions, which have strengthened the scientific clarity of our article. We address the key points regarding dose selection, sample size estimation, temperature monitoring, and methodological considerations as follows: RATIONALE FOR NALBUPHINE DOSE SELECTION Multiple previous studies have demonstrated that nalbuphine is effective in treating postspinal and postoperative shivering, with most reporting mean effective doses ranging from 0.05 to 0.1 mg/kg. Sun et al. observed that a dose of 0.07 mg/kg resulted in a mean cessation time of 3.5 ± 2.7 min for shivering following administration, a similar dose used by Megalla et al.1,2 Furthermore, other comparative studies, such as the one by Kyokong et al., evaluated nalbuphine, tramadol, ondansetron, and placebo, further supporting the dosing range used in clinical practice. In these studies, lower doses, such as 0.05–0.07 mg/kg, also demonstrated efficacy, suggesting that even these relatively smaller doses are sufficient for controlling shivering in many clinical scenarios.3 Given this background, we selected the 0.05 mg/kg dose to systematically analyze its efficacy and to determine whether an even lower minimally effective dose could achieve cessation of shivering, potentially minimizing side effects. Our approach is consistent with the literature, aiming to balance efficacy and safety while contributing additional data on the dose–response relationship for nalbuphine in this context. RELATIONSHIP BETWEEN DOSE, SHIVERING GRADES, AND SAMPLE SIZE ESTIMATION Our sample size estimation was based on effect sizes and shivering grades reported in published studies and was calculated to ensure adequate power to detect clinically meaningful differences while accounting for variability in shivering severity. By anchoring our sample size to validated outcome metrics with appropriate statistical rigor, we ensured the study’s capacity to produce reliable and generalizable findings. The use of graded shivering severity for randomization and sample size calculation aligns with best practices in clinical trial design, allowing focused detection of dose effects on clinically relevant outcomes. TEMPERATURE MONITORING METHODOLOGY The absence of core temperature monitoring in our study is recognized as a limitation. The logistical constraints and invasiveness associated with core temperature monitoring in routine practice often lead to reliance on peripheral or axillary measurements. However, as rightly referenced by Megalla and Mansour, and echoed in recent reviews, the core temperature monitoring should be considered for future research based on the feasibility while examining shivering or hypothermia.4 INFLUENCE OF SURGICAL TYPE AND PATIENT FACTORS The potential impact of surgical site and nature on intraoperative heat loss and shivering incidence is well recognized. Randomized allocation was employed to achieve balanced distribution of surgical categories across groups, effectively minimizing confounding by surgical factors. While detailed subgroup analyses could further enhance interpretability, the randomized controlled trial design remains the most robust method to ensure valid comparison of nalbuphine doses across representative patient populations. Lastly, the impact of patient anxiety on the incidence and severity of postspinal shivering is increasingly recognized. The psychological state of patients undergoing neuraxial procedures can modulate thermoregulatory responses and shivering thresholds. Incorporation of anxiety assessment and its correlation with shivering would be a valuable addition to future studies. In summary, the points raised regarding core temperature monitoring, surgical factors, shivering grading, and patient anxiety are all relevant and appreciated. These considerations have been noted as limitations and areas for improvement in subsequent work, ensuring robust, comprehensive, and clinically meaningful research methodology. Data availability statement Available on request. Author contribution Dr. Sonalika Tudimilla has written the text, and Dr. Chhaya M Suryawanshi has approved it. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Suryawanshi et al. (Wed,) studied this question.