Reactions 1093 - 18 Mar 2006

SBupivacaine

Persistent hiccups following attempted interscalenebrachial plexus block: case report

A 38-year-old man developed persistent hiccups followingattempted interscalene brachial plexus block with bupivacainefor arthroscopic shoulder injury repair.

The man received IV sedation with midazolam and fentanyl.After negative aspiration, bupivacaine 0.5% with epinephrine[adrenaline] was injected in 5mL increments. After receiving15mL, his HR increased from 86 to 120 beats/min, thendecreased to 58 beats/min and returned to baseline over oneminute; his BP also increased. He experienced lightheadedness, which resolved as his HR normalised. The needlewas withdrawn slightly, followed by a 5-minute waitingperiod. A further 25mL of local anaesthetic was injectedincrementally. He said his arm felt ’heavy’. Generalanaesthesia was induced as planned with propofol andmaintained with sevoflurane in 50:50 air/oxygen. A low opioidrequirement was initially thought to represent successfulblock, but he reported severe pain at the surgical site while inthe recovery room. He received oxycodone andhydromorphone and was discharged the next day. However,2 days later, he returned reporting persistent hiccups sincesurgery, nausea and insomnia.

The man was readmitted and received chlorpromazine,metoclopramide and ondansetron; his hiccups improvedenough to allow him to sleep. The next day, thechlorpromazine dosage was decreased and he receivedbaclofen; the frequency of his hiccups decreased, but theintensity appeared to increase. He was discharged withimprovement in his hiccups and a regimen of baclofen andchlorpromazine. His hiccups stopped the next day; at 18 daysafter surgery, he had stopped his medication and his hiccupshad not returned. He remained hiccup-free 1 month later.

Author comment: "In our patient, we postulate that thehiccups resulted from phrenic nerve irritation at the level ofC6 after perineural local anesthetic injection."Homer JR, et al. Persistent hiccups after attempted interscalene brachial plexusblock. Regional Anesthesia and Pain Medicine 30: 574-576, No. 6, Nov-Dec 2005- USA 801032418

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Reactions 18 Mar 2006 No. 10930114-9954/10/1093-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved