Anesth Analg 2001;93:791-792
© 2001 International Anesthesia Research Society
GENERAL ARTICLES
Atropine for the Treatment of Hiccup After Laryngeal Mask Insertion
Noriaki Kanaya, MD,
Masayasu Nakayama, MD,
Junko Kanaya, MD, and
Akiyoshi Namiki, MD
Department of Anesthesiology, Sapporo Medical University, School of Medicine, Sapporo, Japan
Address correspondence and reprint requests to Noriaki Kanaya, MD, Department of Anesthesiology, Sapporo Medical University, School of Medicine, S-1, W-16, Chuo-ku, Sapporo 060-8543, Japan. Address e-mail to kanaya{at}sapmed.ac.jp
 |
Abstract
|
|---|
IMPLICATIONS: We describe three patients in whom hiccups were treated successfully by atropine. Although further clinical investigation is needed, atropine may be useful in the treatment of hiccups after the laryngeal mask airway insertion.
|
Introduction
|
|---|
After laryngeal mask airway (LMA) insertion, hiccups is observed in 1%–14% of patients (1,2). Although hiccups is a common and benign phenomenon, it may disturb surgery. We describe three patients in whom hiccups were treated successfully by atropine.
|
Case Reports
|
|---|
Case 1
A 57-yr-old woman was scheduled for mastectomy. She had no history of gastrointestinal, neurological, or respiratory diseases. The patient received 2 mg midazolam intramuscularly (IM) 60 min before surgery. After preoxygenation, anesthesia was induced with propofol 2.5 mg/kg IV. The LMA (#3) was inserted smoothly. Hiccups occurred after inflation of the LMA cuff. Because ventilation was maintained, anesthesia was followed by 3% sevoflurane; however, the hiccups persisted. Atropine 0.5 mg was then administered IV, and within 1 min the hiccups disappeared. The surgery was completed without further recurrence.
Case 2
A 45-yr-old woman was scheduled for mastectomy. She had no history of gastrointestinal, neurological, or respiratory diseases. The patient received 2.5 mg midazolam IM 60 min before surgery. After preoxygenation, anesthesia was induced with propofol 2.5 mg/kg IV. The LMA (#3) was inserted smoothly. Hiccups occurred after inflation of the LMA cuff. An additional dose of propofol (1.5 mg/kg, IV) and 3% sevoflurane failed to improve the symptom. Finally, the hiccups stopped 2 min after 0.5 mg atropine IV. Anesthesia was maintained with 50% nitrous oxide and 2% sevoflurane. The surgery was completed without further recurrence.
Case 3
A 58-yr-old woman was scheduled for mastectomy. She had no history of gastrointestinal, neurological, or respiratory diseases. The patient received 2 mg midazolam IM 60 min before surgery. Although the LMA (#3) was inserted smoothly with propofol 2.5 mg/kg IV, hiccups occurred after inflation of the LMA cuff. Repositioning of the LMA, an addition of 1.5 mg/kg propofol IV, and inhaled 3% sevoflurane were ineffective. Finally, the hiccups stopped 2 min after 0.5 mg atropine IV. Anesthesia was maintained with 50% nitrous oxide and 2% sevoflurane. The surgery was completed without further recurrence.
|
Discussion
|
|---|
A hiccup is a sudden, involuntary spasmodic contraction of the diaphragm and external intercostal muscles that results in inspiration that abruptly ends with closure of the glottis (3). Although the physiological role remains unknown, hiccups is usually short-lived, uncomplicated, and occasionally affects healthy subjects (3,4). The hiccup reflex is comprised of afferent pathways–vagal, phrenic, and sympathetic (T6-12) branches. The efferent pathways are composed of the phrenic nerve to the diaphragm and nerves to the glottis and the external intercostal muscles. The central connection is the spinal cord (C3-5), possibly controlled by supraspinal pathways (3,4). Therefore, a stimulation at any afferent pathways can trigger the hiccup reflex.
One might argue that the hiccups were simply transient events. We experienced another patient who hiccuped after the LMA insertion before we used atropine. The hiccups persisted despite an additional dose of propofol. Application of hyperventilation with a large concentration of sevoflurane failed to abolish the hiccups. These maneuvers were performed for approximately seven minutes. Because it was difficult to start the operation, we decided to use a muscle relaxant. The hiccups finally stopped two minutes after vecuronium 4 mg IV. Similarly, we spent approximately five minutes for treatment of hiccups in our present case report. Therefore, we believe that the hiccups were not simply transient events.
We speculate that at least two factors are involved in the cause of hiccups after insertion of the LMA. First, a rapid expansion of oropharyngeal and/or upper esophageal space may stimulate the vagus nerve, resulting in hiccups. Also, rapid swallowing of a large bolus of food can induce hiccups. Similarly, inflation of the LMA cuff may cause hiccups via stimulation of vagus. In fact, a rapid phasic distension of the proximal esophagus can cause hiccups in normal subjects, but a slow ramp distension or distal esophagus does not cause hiccups (5). Therefore, a sudden rapid stretch of the mechanoreceptors in the pharynx might trigger the hiccup reflex. If this is true, atropine should be effective in relieving a vagal reflex. Indeed, cervical epidural block for blocking the vagus and/or the phrenic nerve is effective in postoperative intractable hiccups (6). However, blocking of the sympathetic nerve chain (T6-12) by thoracic epidural block was ineffective (6). These supportive findings also show that the LMA insertion-induced hiccups is mediated via stimulation of the hiccup reflex arch by peripheral irritation of the vagus nerve.
Second, propofol may be considered causative of hiccups. Thompson and Landry (7) reported drug-induced hiccups. In their report, corticosteroids and benzodiazepines were the most common drugs suspected of causing hiccups. Because propofol depresses airway reflexes more than thiopentone (8) and therefore allows easy insertion of the LMA with reduced incidence of side effects (e.g., coughing, gagging, or laryngospasm), propofol was unlikely the sole reason for hiccups. In fact, hiccups were observed less frequently after LMA insertion during propofol anesthesia than with midazolam and thiopentone (1). Bapat et al. (1) reported that the incidence of hiccups was 2%, 4%, and 14% after LMA insertion in propofol, lidocaine plus thiopental, and midazolam plus thiopental anesthesia, respectively. Therefore, propofol may play a minor role in the drug-induced hiccups.
Because the hiccup reflex arc is complex, the precise mechanism(s) of action of atropine in the suppression of hiccups are not known from our case report. Nevertheless, we postulate two possible mechanisms of action for the suppression of hiccups by atropine. First, atropine could act directly on the esophagus by means of decreasing intraesophageal pressure. Because atropine can completely abolish the effects of muscarinic receptor agonists, which increase tone and motility of the gastrointestinal tract, atropine might reduce the peripheral mechanoreceptor-mediated reflex by decreasing intraesophageal pressure. Second, atropine may act indirectly on the central nervous system via enhancement of sympathetic nerve activity. Because the usefulness of ephedrine for treatment of intraoperative hiccups was reported (9), the sympathetic stimulation might play some role in the suppression of hiccups. Although further clinical investigation is needed, atropine may be useful in the treatment of hiccups after the LMA insertion.
|
References
|
|---|
-
Bapat P, Joshi RN, Young E, Jago RH. Comparison of propofol versus thiopentone with midazolam or lidocaine to facilitate laryngeal mask insertion. Can J Anaesth 1996; 43: 564–8.[Abstract/Free Full Text]
-
Brown GW, Patel N, Ellis FR. Comparison of propofol and thiopentone for laryngeal mask insertion. Anaesthesia 1991; 46: 771–2.[ISI][Medline]
-
Loft LM, Ward RF. Hiccups. A case presentation and etiologic review. Arch Otolaryngol Head Neck Surg 1992; 118: 1115–9.
-
Kolodzik PW, Eilers MA. Hiccups (singultus): review and approach to management. Ann Emerg Med 1991; 20: 565–73.[ISI][Medline]
-
Fass R, Higa L, Kodner A, Mayer EA. Stimulus and site specific induction of hiccups in the oesophgus of normal subjects. Gut 1997; 41: 590–3.[Abstract/Free Full Text]
-
Sato S, Asakura N, Endo T, Naito H. Cervical epidural block can relieve postoperative intractable hiccups. Anesthesiology 1993; 78: 1184–6.[ISI][Medline]
-
Thompson DF, Landry JP. Drug-induced hiccups. Ann Pharmacother 1997; 31: 367–9.[Abstract]
-
McKeating K, Bali IM, Dundee JW. The effects of thiopentone and propofol on upper airway integrity. Anaesthesia 1988; 43: 638–40.[ISI][Medline]
-
Sohn YZ, Conrad LJ, Katz RL. Hiccup and ephedrine. Can Anaesth Soc J 1978; 25: 431–2.[ISI][Medline]
Accepted for publication May 15, 2001.
This article has been cited by other articles:
|
|
|
|
 
H. S. Smith and A. Busracamwongs
Management of hiccups in the palliative care population
American Journal of Hospice and Palliative Medicine,
March 1, 2003;
20(2):
149 - 154.
[Abstract]
[PDF]
|
|
|
Top
Abstract
Introduction
