TIVA then Hiccups.

[epidural man]

Wish I had read this thread a few days ago...

Hiccups with lma

Anyone ever have this? What do you guys do?

forums.studentdoctor.net

But don’t you think this is weird? I was running a TIVA with LMA (Propofol mixed with alfentanil) and about an hour in, the patient starts doing the hiccup thing.
I’ve seen it after placement - never like this though.

tried more Propofol. Didn’t help. Then did sux 20mg. Helped for one minute. Then repeated sux with 40mg. Helped for a little longer. It was annoying. I just pulled the damn thing out and that seemed to work.

I wonder if it could be a sort of reflex arch with the LMA and nothing to do with pharmacology.
Just a thought...

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[epidural man]

No thoughts on this? I’m a little surprised. This group can be a little verbose....😁

 

[coffeebythelake]

No thoughts on this? I’m a little surprised. This group can be a little verbose....😁

Light anesthetic?

 

[woopedazz]

Bad anaesthetist most likely

 

[BLADEMDA]

To the Editor:​

I would like to report a simple and effective method for treating hiccups that developed after inserting a laryngeal mask airway (LMA) after a propofol induction. I recently had five patients who developed hiccups in this setting. All responded within approximately 30 s to 10 mg of IV metoclopramide.

The incidence of hiccups with LMA placement is reported to be 5% (1) to 15% (2). Hiccups during anesthetic induction have been associated with gastric reflux (3). Metoclopramide has been found effective for the treatment of intractable hiccups in nonanesthetized patients (4), consistent with my recent experience.

Gail R. Pinczower, MD

Department of Anesthesia

Evergreen Medical Center

Kirkland, WA

Stop Those Hiccups! : Anesthesia & Analgesia

An abstract is unavailable.

journals.lww.com

 

[BLADEMDA]

ntranasal Ethyl Chloride spray to terminate Propofol induced hiccups​

Eyston Vaughan-Huxley
BJA: British Journal of Anaesthesia, Volume 113, Issue eLetters Supplement, 29 December 2014, Intranasal Ethyl Chloride spray to terminate Propofol induced hiccups
Published:

29 December 2014

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One of the recognised side effects of propofol is hiccups[1], which can be particularly unfavourable due to the risk of failed supraglottic airway ventilation, disruption to the surgical or radiological field and aspiration[2]. There has been much discussion in the literature regardingthe aetiology of hiccups. It is postulated that during anaesthesia, hiccups can be caused by gastric distension, diaphragmatic manipulation orrapid expansion of oropharyngeal and upper oesophageal space, causing vagal stimulation. There does not appear to be a clear hypothesis for hiccups caused specifically by propofol.
Several techniques to alleviate hiccups have been described, including increasing depth of anaesthesia or administration of antiemetics[3], atropine, intravenous lignocaine [4] or the use of smellingsalts [5].
Our technique involves the administration of a single spray of Ethyl Chloride to each nasal cavity with a nearly 100% success rate of immediatetermination of propofol induced hiccups. Ethyl Chloride has been used previously for this purpose but the spray has been applied to the sternocleidomastoid muscles with the belief that the cooling effect of thespray inhibits phrenic nerve conduction[6]. Successful use of intranasal Ethyl Chloride spray has been described but in the context of Midazolam inthe paediatric population [7]. Authors attribute the mechanism of action in this case to be via cold nasopharyngeal stimulation. There is little inthe published literature on the use of this technique for the termination of propofol induced hiccups in adults, although online forums have some mention of similar techniques.
In our experience the use of intranasal Ethyl Chloride is a safe and effective method for cessation of hiccups. The intranasal route for administration of Ethyl Chloride was described as early as 1907 [8] and literature review does not suggest any adverse effects. Additionally, the intranasal route of administration reduces intravenous polypharmacy. We would welcome any suggestions, comments or experience of using this technique and any alternative methods for terminating hiccups in this context.
References
1. Khan K. Muscle twitching and hiccups with propofol. J Anaesthesiol Clin Pharmacol. 2011 Jul;27(3):418.
2. McVey FK, Goodman NW. Gastro-oesophageal reflux on induction of anaesthesia. Anaesthesia 1992; 48: 92???93.
3. Madanagopolan N. Metoclopramide in hiccups. Curr Med Res Opin 1975;3:371-
4. Landers C, Turner D, Makin C, Zaglul H, Brown R. Propofol associated hiccups and treatment with lidocaine. Anesth Analg. 2008 Nov;107(5):1757-8.
5. Bannon MG. Termination of hiccups occurring under anesthesia. Anesthesiology. 1991 Feb;74(2):385.
6. Dhruva B. Ethyl Chloride spray [Internet]. Bmj.com. 2014 [cited 21November 2014].
7. Marhofer P, Glaser C, Krenn CG, Grabner CM, Semsroth M. Incidence and therapy of midazolam induced hiccups in paediatric anaesthesia. Paediatr Anaesth. 1999;9(4):295-8.
8. A guide to the administration of ethyl chloride. Barton GAH. HK Lewis. 1907.

 

[BLADEMDA]

Drug Treatment​

Apart from the well-known chlorpromazine approved to treat hiccups, many other drugs have been tested and recommended. For example, anticonvulsants in various preparations are indicated to treat intractable hiccups. Gabapentin, an alpha-2-delta ligand with structural similarity to GABA and the ability to block voltage-operated calcium channels to reduce release of several neurotransmitters including glutamate and substance P and finally to modulate the diaphragmatic activity, was promising and safe to treat intractable hiccups.25,41,60 Overall, the response rates of gabapentin ranged from 66.7% to 88.4%. Reported side effect of gabapentin is sleepiness.41 Baclofen, a GABA derivative, has been used to treat hiccup due to CNS tumors and chronic renal failure.19,59 However, baclofen should be used very cautiously in elderly subjects and those with renal failure because of the side effects such as nephrotoxicity, over sedation, ataxia and confusion.59,61 Carvedilol, a potent non-cardio selective beta-blocker, calcium channel blocker and antioxident used to treat tardive dyskinesia of chorea, was also tried in intractable hiccup effectively.62 Besides, 5-HT agonist, for example, tandospirone (affinity to 5-HT1A) was also promising to treat stroke related hiccup because of direct inhibition of phrenic nerve activity via centrally located receptors.11 Olanzapine, a serotonergic antagonist with action on post-synaptic receptors, was also used to diminish the phrenic motor neuron activity to treat hiccup of a brain injury case.21 Midazolam, a benzodiazepine, acts on benzodiazepine receptors to form the benzodiazepine-GABA receptor-chloride ionophore complex in gating chloride channels which leads to hyperpolarization to inhibit neuron firing and to decrease neuronal depolarization. When combined with morphine, midazolam did control the intractable hiccup in a cancer patient.63 Amantadine, acting as a low-affinity antagonist at the N-methyl-D-aspartate subtype of glutamate receptors, has been used as anti-PD therapy because over-activity of glutamatergic transmission is one of mechanisms leading to PD; this agent was successfully used to treat postoperative hiccup in a cancer patient.8 Traditionally, prokinetics have been widely used to treat hiccups because stomach distension is considered as one of the mechanisms leading to hiccups.64 In fact, premedicated metoclopramide treatment did effectively prevent the anesthesia induced hiccup.65 Lidocaine can stabilize cell membrane by blocking sodium channels to reduce neuronal excitability. It has been used successfully in treating or pre-treating intractable hiccups induced via many measures.57,66,67 Other miscellaneous agents used to treat hiccup include calcium channel blockers and antidepressants.8

Hiccup: Mystery, Nature and Treatment

Full-Young Chang and Ching-Liang Lu. J Neurogastroenterol Motil 2012;18:123-30. https://doi.org/10.5056/jnm.2012.18.2.123

www.jnmjournal.org