Hiccups

[John Farnsworth]

I have a question about a common problem that is usually just a nuisance, but occassionally a hindrance.

Hiccups post induction.

Probably 10% of my LMA patients exhibit hiccuping after induction. Usually settles down after a a few minutes. Extra propofol does not seem to obliterate it. And occassionally I have had the hiccups get worse and worse, rather than better and better, to the point where the patient eventually gets stridorous or spasmy (is that an adjective?).

Any ideas on how to minimise it?

My usual anesthetic for spont resp LMAs is midazolam about 1-3mg, fentanyl 25mcg, propofol 120-160mg for the avergae adult.

[George Miklos]

Well, well, well.

In the not-so-old days (pre-propofol) it wasa well-known adage that you do not fiddle witht he airway until the patient is deeply anesthetised. Thiopentone was just the start of the induction process, not the entirety of it. After the IV induction, the patient would be deepened with volatile and then the pharynx was commonly topically anesthetized, BEFORE any stimulation of the airway.

Nowadays, we have propofol and many of us have lost the art of a true induction. Propofol gets you no deeper than thio, but it is more forgiving in terms of airways reflexes. We commonly start manipulating the airway long before the patient is deep (if you use TCI, you will note the brain concentration of propofol lags behind the IV concentration by several minutes) and rely on propofol's inate inhibition of airway reflexes to insert the LMA.

My message is this - you are inserting the LMA long before the patient is deep. Induce with propofol by all means, then use a volatile to deepen the patient (and this time allows the propofol to actually cross the blood-brain-barrier), and only then inser the LMA. No hiccups.

[Russell Coupland]

Well, well, well.

In the not-so-old days (pre-propofol) it wasa well-known adage that you do not fiddle witht he airway until the patient is deeply anesthetised. Thiopentone was just the start of the induction process, not the entirety of it. After the IV induction, the patient would be deepened with volatile and then the pharynx was commonly topically anesthetized, BEFORE any stimulation of the airway.

Nowadays, we have propofol and many of us have lost the art of a true induction. Propofol gets you no deeper than thio, but it is more forgiving in terms of airways reflexes. We commonly start manipulating the airway long before the patient is deep (if you use TCI, you will note the brain concentration of propofol lags behind the IV concentration by several minutes) and rely on propofol's inate inhibition of airway reflexes to insert the LMA.

My message is this - you are inserting the LMA long before the patient is deep. Induce with propofol by all means, then use a volatile to deepen the patient (and this time allows the propofol to actually cross the blood-brain-barrier), and only then inser the LMA. No hiccups.

Ditto to all the above, but also:

Midazolam in high-ish doses (3-5mg) predisposes to hiccups. I do a lot of GI sedation with midazolam, and hiccups are common soon after the midaz starts to kick into effect.

[Bucky]

I was having great trouble with this very issue until I mentioned it to our desflurane manufacturer's representative.  She asked me to describe exactly how I was proceeding with my inductions and made a subtle change suggestion which was proffered to her by an anesthesiologist elsewhere.

The suggestion was to be sure that the product of the fresh gas flowrate times the inspired concentration of des is not higher than 24.  Now typically, I use 3 LPM and 8% des as my post-induction mixture.  In the last 100 or so LMA cases with desflurane, I've not seen any hiccoughs (or other coughing).  Prior to that I was using the likes of 6-8 LPM and 8%-10% des., I was seeing hacking, coughing and hiccoughs at least 25% of the time.

My usual LMA induction: fentanyl 2 ml + 2 mg/kg propofol (with 40mg lidocaine) (sometimes I add midazolam 2 mg to the induction.)

[Michael de Sousa]

Plus injecting propofol slowly rather than as a "bomb" makes for a smoother induction with less airway irritibility.

[drclaudiap]

Slow it down and maybe a little more fentanyl!!
good side...they won't remember it!!  ;)

[gnf]

I had a patient for port-a-cath insertion, preop fentanyl with propofol infusion only. Starting to hiccup on a regular basis during case. Need to know how to control, not an issue for this case, but could be .......

[conideo]

hi there:

I'm a 3º year resident from Lisbon, Portugal.
From the story you're telling, it seems to me the patient wasn't deep anesthethised enough.
My little experience tells me the patient has to be deep enough to insert the LMA.
Usually we do as drugs diazepam 5-10mg and propofol 150-200mg quite fast. Like that the quality of the deepness is greater. I dont give fentanyl until they´re about to start the procedure (0,05mg). the results are the follow: the stimuli of the LMA is enough for the patient to start breathing spontaneously again (no need for fentanyl when induction! no need for assisted ventilation!) ; haemodynamic stability ; NO HICCUPS!!!! hope it will helps