To the Editor:—
Almost everyone has had the hiccups at one time or another. These involuntary contractions of the diaphragm and respiratory muscles that terminate with abrupt closure of the glottis—or “hiccups”—are usually transient and do not herald any serious pathology. Occasionally, hiccups persist, lasting hours, days, or weeks. Hiccups lasting longer than 48 h are termed “persistent” and those lasting longer than a month are termed “intractable.” Persistent or intractable hiccups may be the presenting symptom of serious pathology.
Despite the varied possible etiologies, in the majority of cases no organic causes can be identified and a diagnosis of idiopathic chronic hiccups is made. As expansive as the potential causes is the list of potential cures. Home remedies such as breath holding, a glass of water, and even a scare to evoke a startle reflex have been tried. Pharmacologic interventions are just as varied. Indeed, several agents used to cure hiccups (i.e., midazolam and dexamethasone) have anecdotally been suspected as causative agents. Having exhausted pharmacologic remedies, some have tried more invasive techniques such as acupuncture, glossopharyngeal nerve block, phrenic nerve block, and even general anesthesia.
We treated one patient with the use of the transesophageal atrial pacing probe to alleviate his persistent hiccups after revision of a right hip prosthesis.
The patient was a 76-yr-old man with a history of osteoarthritis and right total hip arthroplasty, who returned to the operating room for revision of a painful loose acetabular implant. Preoperatively, the patient had a lumbar epidural catheter placed in the holding area. He was given midazolam 2 mg intravenously for sedation without complication. He underwent revision of the right hip prosthesis under general anesthesia without incident. The epidural was bolused with bupivacaine 0.25% before emergence. The patient was extubated in the operating room and transported to recovery, where a continuous infusion of 0.0625% bupivacaine and fentanyl 10 μg/ml at a rate of 3.5 ml/h was started. On rounds the next morning, the patient complained of hiccups that had started the evening before and persisted through the night. He denied any other symptoms and rated his pain control as good. Physical exam was unremarkable except for persistent hiccups. Initial pharmacologic interventions included Thorazine 10 mg, twice, Dilantin 200 mg, and lidocaine 100 mg intravenously; all failed to resolve the hiccups. Next, topical lidocaine spray applied to the oropharynx was tried without relief. Finally, after topical anesthesia with Cetacaine spray was achieved, the patient swallowed the 18-French transesophageal atrial pacing probe (Tapscope model 550F; CardioCommand, Tampa, FL). The probe was connected to the pulse generator (Tapsystem model 2A; CardioCommand) and the diaphragm was paced at a rate of 80 bpm with 20 mA output for 15 s. The generator was then turned off and the patient’s hiccups had resolved. The hiccups did not reoccur for the remainder of his hospitalization.
Our patient had reported persistent hiccups after his original total hip arthroplasty. The hiccups had lasted for more than 1 week. The patient had tried mints, which helped but did not resolve the hiccups. For both procedures, our patient had had an epidural placed for postoperative pain control. In addition, our patient had received midazolam for sedation during epidural placement, another possible cause for the hiccups. However, no other organic cause for the hiccups was identified.
Gastroenterologists have advocated cisapride, omeprazole, and baclofen as the initial treatment for patients with persistent hiccups. However, the results of transesophageal atrial pacing probe pacing the diaphragm produced rapid and complete relief. Treatment parameters of frequency and duration were estimates based on clinical experience and patient comfort. Amplitude and probe position was assessed objectively by successful diaphragmatic pacing as determined by changes in respiratory pattern.
It should be noted, however, that the transesophageal atrial pacing probe is not an entirely benign intervention. Future applications of transesophageal atrial pacing probe placement for diaphragmatic pacing should include standard monitors (blood pressure, electrocardiogram, and pulse oximetry) to insure patient safety. In our case, the transesophageal atrial pacing probe for the resolution of persistent hiccups worked; however, a randomized prospective study is warranted to more fully evaluate the efficacy and safety of this treatment modality.
Special thanks to Jolene Bean-Lijewski, M.D., Ph.D., Associate Professor of Anesthesiology, and Jeff R. Gibson, Jr., M.D., Assistant Professor of Anesthesiology, Scott and White Memorial Hospital, Texas A&M University College of Medicine, Temple, Texas, for their editorial talents in reviewing this letter.
* Scott and White Memorial Hospital, Temple, Texas. firstname.lastname@example.org