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LETTERS TO THE EDITOR

Hiccupping and Regurgitation via the Drain Tube of the ProSeal Laryngeal Mask

Department of Anesthesiology, Lahey Clinic, Burlington, MA Department of Gastroenterology, Lahey Clinic, Burlington, MA

To the Editor:

A healthy 40-yr-old female (165 cm, 61 kg) presented for transanal excision of a rectal polyp under general anesthesia. The patient had fasted since midnight. She was induced with propofol 150 mg IV and mask ventilated with oxygen for 20 s. A size 4 ProSeal^TM laryngeal mask airway (PLMA) was inserted using the index finger method and the cuff was inflated to 60 cm H₂O. Mask placement was considered satisfactory based on normal chest rise and fall, feel of the anesthesia bag, and the capnograph. The maximum seal pressure exceeded 30 cm H₂O positive pressure ventilation. Shortly thereafter the patient began hiccuping; this persisted despite additional propofol, fentanyl, and an increased inspired sevoflurane concentration. A small jet of gastric juice was then ejected from the drain tube (DT) of the PLMA in association with the hiccupping. After expulsion of the gastric juice, a fluid level was observed in the DT. Ventilation remained unimpaired and there were no indications of airway contamination. Rocuronium 50 mg IV was administered and the anesthetic converted to positive pressure ventilation. A 14F orogastric tube was passed via the DT and over 200 mL of gastric fluid was suctioned. Anesthetic maintenance and emergence proceeded routinely and examination of the PLMA at the end of the case did not reveal any evidence of contamination within the bowl. The patient had an unremarkable recovery.

Hiccupping consists of a spasmodic contraction of the diaphragm and accessory muscles followed by active closure of the glottis (1). It is a powerful reflex that can result in markedly negative intrathoracic pressures. Hiccupping causes increased peritoneal (gastric) pressures and a decrease in lower esophageal sphincter (LES) tone (1). LES function can be overcome by the transient peritoneal-pleural gradient created during a hiccup. As such, hiccupping favors reflux of gastric contents into the esophagus and, in anesthetized patients, is a risk factor for regurgitation and aspiration (2,3). According to Vanner (3), about 40% of patients who hiccup after induction of anesthesia develop detectable gastroesophageal reflux. In the majority of these cases, the upper esophageal sphincter (UES) prevented further regurgitation into the pharynx (3).

Hiccupping resembles breathing against an obstructed airway. Breathing against an obstructed airway, in turn, is known to be a risk factor for regurgitation and aspiration as summarized by Ovassapian: "In order for gastric regurgitation to occur, several conditions must usually be present. There needs to be fluid in the stomach, the cardioesophageal junction must prove to be incompetent, the pressure within the stomach exceeds that in the esophagus, and the cricopharyngeus muscle allows material to pass into the oropharynx" (4–6). In our case, we believe that repeated hiccupping caused gastric contents to accumulate in the esophagus. Eventually a jet of gastric juice was expelled from the esophagus through the DT. The DT provided a low-resistance channel through which fluid in the esophagus was vented to the outside. The DT may have played a role in partially stenting open the UES, but this remains unknown.

In summary, this case highlights the risk of hiccupping in anesthetized patients. More generally it illustrates one process, gastroesophageal reflux, that can occur with negative intrathoracic pressures (1–6). The PLMA was designed with a DT to channel regurgitated esophageal contents that reach the UES to the outside. The PLMA was also designed with a large bulky cuff near the tip to provide a measure of isolation between the respiratory and gastrointestinal tracts. Any measure of airway protection afforded by the PLMA is dependent on the quality of the cuff seal with the hypopharynx and force of regurgitation (7). In this case, the PLMA seems to have worked in the manner for which it was designed. There was no clinical evidence of airway contamination during this case of regurgitation associated with hiccupping.

References

1. Marshall JB, Landreneau RJ, Beyer KL. Hiccups: esophageal manometric features and relationship to gastroesophageal reflux. Am J Gastroenterol 1990; 85: 1172–5.[Medline]
2. McVey FK, Goodman NW. Gastro-oesopohageal reflux and hiccough on induction of anaesthesia. Anaesthesia 1992; 47: 712.
3. Vanner RG. Gastro-oesophageal reflux and hiccup during anaesthesia. Anaesthesia 1993; 48: 92–3.
4. Ovassapian A. Fiberoptic endoscopy and the difficult airway. 2nd ed. Philadelphia: Lippincott-Raven Publishers, 1996.
5. Marchand P. The gastro-oesophageal ‘sphincter’ and the mechanism of regurgitation. Br J Surg 1955; 42: 504–13.
6. Dinnick OP. Hiatus hernia: an anaesthetic hazard. Lancet 1961; 1: 470–3.
7. Brimacombe J, Keller C. Airway protection with the ProSeal laryngeal mask airway. Anaesth Intensive Care 2001; 29: 288–91.[ISI][Medline]

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Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999