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.

There are pediatric-size Univent tubes that allow the passage of a pediatric size bronchoscope for placement. The alternative is blind placement of the Univent bronchial blocker or a Fogarty catheter, test ventilate and check which side it has gone to. If the wrong side, the pull back, twist 180^o and re-insert. A bit fiddly, but only has to be done once. Then blowing up the balloon and deflations do not require any further manipulations.

I had a similar mysterious (and stressful) situation during my training. My very experienced obstetric anaesthetic collegue explained it thus: Some pregnant women have extremely twitchy pulmonary circulation which is very sensitive to intubation. That is, the act of intubating can trigger a catastrophic pulmonary hypertension which can cause this effect.

A went on to do a quick literature search which showed that most women, and especially pre-eclamptic women demonstrate a rise in pulmonary pressures during intubation which in the extreme case could cause severe hypoxia.

I trained in the UK and then worked for 1 year in Boston, USA. I was surprised at how different some things were. The most striking difference in clinical practice which I must admit I have not imported back to the UK is the American practice of doing an inhalational induction in a child, then proceding to secure the airway (either with an LMA or ETT) BEFORE obtaining IV access.

Where I trained, this would be grounds for failing the Finals. What would happen (I can hear the examiner ask) if after induction an one attempt at intubation, the child laryngospams before IV access is obtained?

I know the stock answers: children are almost always easy to intubate, IM sux, CPAP.

Is this common practice in the USA? Or was it just a regional variant?