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경희의학 : 제 30 권 제 1 호
J Kyung Hee Univ Med Cent : Vol. 30, No. 1, 2015
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Continuous Cervical Epidural Block for Persistent Intractable Hiccups
Jung Eun Kim, Mi Kyung Lee, Sang Sik Choi, EuiSeok Park, Gwi Eun Yeo
Department of Anesthesiology and Pain medicine, Korea University Guro Hospital, Seoul, Republic of Korea
Introduction
Case report
Hiccups is the sudden onset of erratic diaphragmatic
Five month prior to his initial presentation in our
and intercostal muscle contraction and immediately
clinic, this 59-year-old man suffered cerebrovascular
followed by laryngeal closure.(1) It consists of a
attack. Immediately following the stroke, hiccups
sudden powerful activation of the inspiratory muscles
began. The hiccups began occurring continuously
of the thorax, diaphragm, neck accessory, and external
during wakefulness and sleep with a periodicity of
intercostal muscles, with brief inhibition of the expi-
every 4 to 5 seconds. The patient became severely
ratory muscles and active movement of the tongue
depressed and experienced difficulty sleeping because
toward the roof of the mouth. Usually hiccups stop
the hiccups were continuous. Multiple medical remedies
within a few hours, but some can not stop. Persistent
were unsuccessful. After 3 months of intractable and
and intractable hiccups typically defined as lasting for
persistent hiccups, the patient presented to pain clinic
more than 48 hours and one month respectively.(2)
department at Korea University Hospital for further
Intractable hiccups often limits a patient’s activities
of daily living and may significantly lower functional
evaluation and treatment. Blood chemistries, chest and
abdominal CT were unremarkable.
status and quality of life. Sometimes intractable hiccups
We assumed that a block of the efferent phrenic
produce severe morbidity including insomnia, fatigue,
nerve block is effective. For treatment of persistent and
malnutrition, weight loss, exhaustion, and even death.
intractable hiccups, we decided to conduct continuous
Despite these potentially fatal complications, definite
cervical block cover the levels supplying the phrenic
treatment strategies are still unknown.(3-5) We describe
nerve (C3-C5).
the case of a patient with intractable hiccups unres-
The patient was given 1 g of cefazolin intravenously
ponsive to pharmacotherapy, who was successfully
prior to the procedure. He was placed on the procedure
treated with continuous cervical epidural block.
table in a prone position. Supplemental oxygen was
delivered through a nasal cannula, and blood pressure,
Corresponding author: Sang Sik Choi, Department of Anesthesiology
and Pain medicine, Korea University Guro Hospital, Guro
2-dong, Guro-gu, Seoul 152-703, Korea
Tel: +82-2-2626-1870, Fax: +82-2-851-9897
E-mail: [email protected]
electrocardiogram, and pulse oximetry were monitored
throughout the procedure. The skin was prepped with
2% alcohol-chlorohexidine and draped in a sterile
fashion. The continuous cervical epidural block was
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− Jung Eun Kim, et al：Continuous Cervical Epidural Block for Persistent Intractable Hiccups −
detection of immediate complications related to the
continuous cervical epidural block.
On the 2nd days after the continuous cervical epidural block, the persistent and intractable hiccups were
stopped.
Discussion
A hiccup is a repeated involuntary, spasmodic
contraction of the diaphragm accompanied by sudden
closure of the glottis.(6) Usually hiccups stop within a
few hours, but some can not stop. Persistent and
intractable hiccups (typically defined as lasting for
Fig. 1. Radiograph shows epidural catheter and the
spread of contrast media. Radiograph shows
bilateral spread of contrast media in the upper
cervical epidural space including C3-C5 after
injection of 1.5mL of water-soluble contrast
media through the catheter
more than 48 hours and one month respectively) can
be of serious detriment to a patient’s quality of life,
although they are relatively uncommon.(2)
But Persistent and intractable hiccup have unknown
etiology. Some are well known to invade the hiccup
reflex arc, whereas many others remain unexplained
performed at the C7-T1 or T1-T2 intervertebral space
why they would elicit persistent or intractable hiccups
with the neck flexed using the loss of resistance tech-
since no obvious invasion to the hiccup reflex pathway
nique with a midline approach.
was confirmed.(7-9)
When the block needle (18 G Tuohy needle) reached
The hiccup reflex arc is customarily divided into an
the cervical epidural space, the correct placement of
afferent limb, a central connection, and an efferent
the needle in the epidural space was confirmed using
part.(10) The afferent portion of the neural pathway of
contrast radiography. Then, a 22 G epidural catheter
hiccup formation is composed of the vagus nerve, the
was advanced cephaladly to the C3-5 level through the
phrenic nerve, and the sympathetic chain arising from
needle. The correct catheter placement was also
T6 to T12.(11) The central connection is localized in
confirmed by radiography with the injection of contrast
the brain stem and a nonspecific area between the C3–
dye via the catheter (Fig. 1). Subcutaneous tunneling
5 spinal levels. The efferent pathways constitute the
was performed for prolonged continuous epidural
phrenic nerve to the diaphragm, direct plexus branches
block. After placing the tunneled epidural catheter, a 6
to the scalene muscles, vagal branches to the glottis,
mL bolus of 0.25% ropivacaine was injected and a
and intercostal nerves to the external intercostal
continuous infusion of 4 mL/h of ropivacaine was
muscles.(12) The pathophysiological disturbance that
administrated
using
causes episodic or intractable hiccups usually involves
infuser containing 0.75% ropivacaine 45 ml and normal
the afferent or efferent neural pathways. Thus, a nerve
saline (total 275 mL). After the procedure, patients
block of some part of this pathway might be an
were monitored for at least 30 minutes for the
effective treatment for hiccups.
through
the
epidural
catheter
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− 경희의학 제 30 권 제 1 호 2015 −
Shigehito et al. conducted thoracic epidural block
Abstract
from T3 to T11 for block of the afferent portion of the
sympathetic nerves in persistent and intractable hiccup
Hiccups is the sudden onset of erratic diaphragmatic
patient.(3) But extended thoracic epidural block from
and intercostal muscle contraction and immediately
T3 to T11 was ineffective. They tried cervical epidural
followed by laryngeal closure. Usually hiccups stop
block from C3 to C5 for block of the efferent portion
within a few hours, but some can not stop. Persistent
in same patient. After cervical epidural block, The
and intractable hiccups typically defined as lasting for
hiccup was stop. Extended cervical block cover the
more than 48 hours and one month respectively.
levels supplying the phrenic nerve (C3-C5) and that
Intractable hiccups often limits a patient’s activities of
was effective in stopping hiccups. So they assumed
daily living and may significantly lower functional
that a block of the afferent portion of the sympathetic
status and quality of life. We describe the case of a
nerves was of no use in stopping hiccups and efferent
patient
phrenic nerve block is effective. So we tried “conti-
pharmacotherapy, who was successfully treated with
nuous” cervical epidural block in persistent and
continuous cervical epidural block. with
intractable
hiccups
unresponsive
to
intractable hiccup and it was successful for treatment.
The concentration of ropivacaine used here was
Key Words: Continuous cervical epidural block, Intrac-
determined empirically. Continuous infusion of 4 mL/h
table hiccups
of ropivacaine was administrated through the epidural
catheter using a disposable balloon infuser (Autofuser,
ACE medical, Seoul, Republic of Korea) containing
References
0.75% ropivacaine 45 mL and normal saline (total 275
mL). To determine the optimal concentrations of local
anesthetics,
however,
further
clinical
studies
are
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