Hiccups during induction

[Dr-Junior]

A 44 year patient, 180 cm tall and 100 kg, undergoing ureteroscopy.
Induction: 0,15 mg Fentanyl and 200 mg Propofol then Guedel tube placed. As I tried to bag the patient he hiccuped 3-4 times so 100mg Propofol were injected then suddenly a gush of clear fluid comes through the mouth.
Then succinylcholine and ETT placed.

I can't figure the reason for hiccups under anesthesia. Was my anesthesia not really deep enough or was it the Guedel?

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[pgg]

Never heard the term "Guedel tube" - I assume you mean an oropharyngeal airway.

Was it hiccups, or gagging?

Hiccups happen, but usually there's no regurgitation. Myotonic movement and hiccups happen 100% of the time with methohexital inductions. Less common with etomidate. Not often with propofol, but it happens.

Stuffing an OPA into an inadequately anesthetized patient will make them gag and sometimes puke. I bet that's what happened.

 

[Dr-Junior]

Yes I mean an oropharyngeal airway. It was hiccups I am sure

 

[Noyac]

Many claim the hiccups are from propofol. I don't agree. I think comes from bagging pts as we induce them. Something irritates their oropharyx or epiglottis causing them to hiccup.
My approach is either continued gentle mask ventilation if I'm planning on an LMA until they subside. If I need to do something else and free up My hands then I give a small dose of sux and place the LMA.

 

[Gern Blansten]

Instead of gastric contents as the source of the fluid, is it possible that it was negative pressure pulmonary edema. It has been described with hiccups on mask induction in a pediatric patient. Did you happen to get an x-ray afterwards? How forceful were the hiccups? Were they against a closed glottis (likely hard to know for sure since they happen so fast)?
http://www.ncbi.nlm.nih.gov/pubmed/10861177
Probably pretty unlikely, but would be in my differential since NPPE can be pretty impressive with regards to the volume of fluid produced.

 

[pjl]

Hiccups are most likely from air in stomach in my opinion.
I find urology patients seem to be prone to poor gastric emptying. If they have a few hiccups I am ok, but lots, I will just tube them. More than once I have had a lot of fluid or other come out of the stomach on urology cases despite "adequate" npo status. I like LMAs, but if I get that feeling I am easily convinced to use an ETT.

 

[GhostTree]

Atropine for the Treatment of Hiccup After Laryngeal Mask Insertion
Kanaya, Noriaki MD; Nakayama, Masayasu MD; Kanaya, Junko MD; Namiki, Akiyoshi MD

Anesthesia & Analgesia:
September 2001 - Volume 93 - Issue 3 - p 791–792
doi: 10.1097/00000539-200109000-00047

 

[GhostTree]

I have definitely experienced hiccups after placing an lma and inflating the cuff. Usually they go away, but after reading the paper above I've tried atropine 0.2mg and it usually works pretty well.

 

[nimbus]

Many claim the hiccups are from propofol. I don't agree. I think comes from bagging pts as we induce them. Something irritates their oropharyx or epiglottis causing them to hiccup.
My approach is either continued gentle mask ventilation if I'm planning on an LMA until they subside. If I need to do something else and free up My hands then I give a small dose of sux and place the LMA.

I almost never bag these days and still occasionally get hiccups.

 

[vector2]

I'm relatively certain it's from air in the stomach based on my anecdotal experiences of this occurring when bagging is somewhat difficult and I've closed the popoff to 20ish+. I've come to see bagging as mostly irrelevant for routine inductions. Think about it...what is your plan on pt with a good appearing airway after you've pushed fent and prop and you unexpectedly can't bag? Wake them up and hope they don't desat in the mean time? Hell no, you're gonna push the sux, (perhaps) see if relaxation aids your ability to ventilate, and just put the tube in.

 

[gasp]

Most of the time I have seen them in my pt's is right after induction and before bag mask. I'm going to blame Propofol. I usually just scare them by yelling in their ear and it usually stops..

 

[Noyac]

Interesting.

I almost never bag these days and still occasionally get hiccups.

 

[deleted162650]

Ok, so those of you that don't routinely bag with inductions, what is your sequence? I rarely use sux except for true RSI indications and ECT's which means I'm usually giving low dose Roc for induction that needs a little while to set up. I guess I could hammer them with prop/fent but most of my pts aren't that healthy. This means I'm bagging for a few before I DL.

Also, I think assessing ease of baggability on induction is useful information to have come time for emergence/extubation.

 

[propadope]

Ok, so those of you that don't routinely bag with inductions, what is your sequence? I rarely use sux except for true RSI indications and ECT's which means I'm usually giving low dose Roc for induction that needs a little while to set up. I guess I could hammer them with prop/fent but most of my pts aren't that healthy. This means I'm bagging for a few before I DL.

Also, I think assessing ease of baggability on induction is useful information to have come time for emergence/extubation.

If not sux, I'm guessing vapour + propofol +/- narcs.

 

[nimbus]

Ok, so those of you that don't routinely bag with inductions, what is your sequence? I rarely use sux except for true RSI indications and ECT's which means I'm usually giving low dose Roc for induction that needs a little while to set up. I guess I could hammer them with prop/fent but most of my pts aren't that healthy. This means I'm bagging for a few before I DL.

Also, I think assessing ease of baggability on induction is useful information to have come time for emergence/extubation.

I mix my roc with propofol and lidocaine in the same syringe. Allows me to hold the mask and push the drugs myself. For most short cases like lap choles I only use 30mg of roc. Works fine.

 

[deleted162650]

I mix my roc with propofol and lidocaine in the same syringe. Allows me to hold the mask and push the drugs myself. For most short cases like lap choles I only use 30mg of roc. Works fine.

That's not really answering my question. 30 of roc is about what I use most of the time as well for similar cases. That dose takes a little while to set up in your typical 70-100kg adult human. Do you just leave the pt apnic while you wait, or do you rush in with the laryngoscope and tolerate some coughing and wiggling when the tube goes in?

P.s. Not criticizing at all here, just curious what you're doing. Always looking for ways to streamline although I don't see forgoing bagging the pt while I let my drugs work. I'm referring to bagging after paralytic goes in, not "test ventilating" which I don't do either.

 

[nimbus]

That's not really answering my question. 30 of roc is about what I use most of the time as well for similar cases. That dose takes a little while to set up in your typical 70-100kg adult human. Do you just leave the pt apnic while you wait, or do you rush in with the laryngoscope and tolerate some coughing and wiggling when the tube goes in?

P.s. Not criticizing at all here, just curious what you're doing. Always looking for ways to streamline although I don't see forgoing bagging the pt while I let my drugs work. I'm referring to bagging after paralytic goes in, not "test ventilating" which I don't do either.

Typically I push the whole syringe, hold the mask on their face until they are apneic, tape the eyes and go. Rarely they wiggle. Most of the time they don't.

And I understand it is a sincere question. Glad you asked. I am also always looking for ways to streamline the workflow.

 

[Noyac]

I almost always bag them a bit. Even when I do an RSI (I guess I only do modified RSI's). I like to give a smaller dose of propofol so I let it work for a while. I will bag them during this time. I release the circulator to start prepping as well.

I almost always save a little propofol for the end of the case. So even bigger guys don't get the full 20cc.

I agree with saltydog, the information I get from bagging them is useful.

 

[deleted162650]

I almost always bag them a bit. Even when I do an RSI (I guess I only do modified RSI's). I like to give a smaller dose of propofol so I let it work for a while. I will bag them during this time. I release the circulator to start prepping as well.

I almost always save a little propofol for the end of the case. So even bigger guys don't get the full 20cc.

I agree with saltydog, the information I get from bagging them is useful

This is a pretty much a carbon copy of how I do things including letting the circulator prep/foley as soon as the pts eyes close. I stick the ETT (half still in the wrapper) under the table mattress or pinch it between my legs so nobody has to hand it to me.

 

[pgg]

I saw someone intubate a patient today and lean down and use his teeth through his mask to grasp and pull the ETT stylet once the tube was in. It was something of a spectacle.

Reason #39 why I prefer to stay out of other people's rooms when they're working.

 

[Ronin786]

This is a pretty much a carbon copy of how I do things including letting the circulator prep/foley as soon as the pts eyes close. I stick the ETT (half still in the wrapper) under the table mattress or pinch it between my legs so nobody has to hand it to me.

Towel clamp to the ETT packaging at the side of the bed next to the patient's head.

I can't imagine pinching it between my legs, someone might grab the wrong tube.

 

[deleted162650]

I saw someone intubate a patient today and lean down and use his teeth through his mask to grasp and pull the ETT stylet once the tube was in. It was something of a spectacle.

Reason #39 why I prefer to stay out of other people's rooms when they're working.

That's fukking hilarious. What was occupying both hands once the tube was in??? Sounds like something you'd see on an anesthesia version of that game show "Minute to Win It"

Towel clamp to the ETT packaging at the side of the bed next to the patient's head.

I can't imagine pinching it between my legs, someone might grab the wrong tube.

I've tried the towel clip thing but I think just sticking it under the mattress or Shea pillow works better.