Propofol Associated Hiccups and Treatment with Lidocaine

Abstract

To the Editor: The appearance of hiccups in patients undergoing medical procedures and under sedation/anesthesia usually constitutes an unwelcome and disturbing occurrence. Triggering events include distention of the stomach during bag-valve-mask ventilation and esophagogastroduodenoscopy, intraoperative manipulation of the diaphragm, and medications such as methohexital, midazolam, and opoids. Although up to 25% of patients receiving methohexitol can develop hiccups,1 propofol is not widely described as being associated with hiccups. We report a child undergoing deep sedation for radiation therapy who developed hiccups after propofol administration. A 3½-yr-old female was scheduled to undergo simulation and radiation therapy to her neck to include 14 individual treatments because of a recurrent Wilm's tumor. She was status post partial nephrectomy and resection of a left neck mass. For each radiation treatment session, she was sedated with propofol, either as an induction bolus alone or as a bolus followed by infusion. Because she had a tunneled central venous catheter in place, lidocaine was not used for prevention of propofol injection site pain. During the first sedation, she developed hiccups almost immediately after administration of propofol. The hiccups resolved and did not interfere with the procedure. The following three treatments were uneventful. However, the fifth sedation was complicated by hiccups with subsequent laryngospasm. The laryngospasm was managed by additional sedation and subsequent support via bag-valve-mask ventilation. Subsequently, on two occasions she developed hiccups after propofol induction which were quickly relieved with lidocaine 1 mg/kg given IV. Propofol is not commonly known to cause hiccups; the package insert reports the incidence of hiccups at <1%. Since lidocaine is commonly administered with or before propofol induction to reduce pain at the injection site, it is possible that hiccups are unknowingly being pretreated, albeit the dose is significantly less than that used to treat hiccups. Pretreatment with lidocaine has been shown to prevent hiccups from methohexitol sedation.2 Hiccups can lead to increased postoperative pain or, in the situation of procedural sedation, the inability to complete the study due to movement (such as in MRI). Adequate treatment for hiccups is unclear with many medications (e.g., haloperidol, methylphenidate) and other topical or stimulating therapies described.3 Lidocaine (both IV4,5 and nebulized6) has been reported in several case studies of intractable hiccups in awake patients. This case seems to support that propofol, like other induction agents, can be associated with hiccups and that lidocaine IV is an effective treatment. Cheri Landers, MD, FAAP Dawn Turner, MD Carrie Makin, RN Horacio Zaglul, MD, DCH, FAAP Department of Pediatrics, Division of Pediatric Critical Care Kentucky Children's Hospital Lexington, Kentucky [email protected] Rae Brown, MD Department of Anesthesiology University of Kentucky Lexington, Kentucky