Phrenic Nerve Block With Ultrasound-guidance for Treatment of Hiccups

A Case Report

Kristiina Kuusniemi*; Ville Pyylampi

Disclosures

J Med Case Reports. 2011;5(493) 

In This Article

Discussion

One of the most frequent causes of self-limited hiccups is overdistension of the stomach, but more than 100 other causes of persistent and intractable hiccups have been described. Not all hiccups are benign, and so a possible underlying disease process must be kept in mind and examined when necessary.[1] In our case, one possible reason for persistent hiccups could be the genucubital position of the patient during the operation. This could cause extension of the neck, which in turn may have resulted in stretching the phrenic nerve roots. Traction on the diaphragm is also possible in the genucubital position.

As the persistent hiccups caused insomnia, exhaustion and made the discharge impossible and since both pharmacological and non-pharmacological treatments had proved ineffective, we ended up using a single-shot US-guided technique with our patient. The phrenic nerve could be demonstrated in his cervical region, despite its thinness, thanks to high-resolution ultrasonography and real-time imaging.

We used a fairly high dose of bupivacaine to ensure the blockade. This dose of bupivacaine actually resulted in a partial blockade of his right shoulder. A more caudal approach to the phrenic nerve and a smaller dose of the local anesthetic would probably have resulted in a lower spread of anesthesia. We considered the 5 mL dose of bupivacaine small enough to avoid its rostral spread to the root C4,[6] although even a smaller dose would probably have been sufficient, US being used to guide local anesthetic injection. Possible side effects also include difficulties in breathing as a consequence of unilateral diaphragmatic block. In this case we did not measure spirometry values in the way some authors have suggested,[5] as our patient did not clinically present dyspneic or have a history of any lung disease. Furthermore, it has been shown that the incidence of diaphragmatic paralysis decreases and the respiratory function is preserved when a low volume of local anesthetic is used.[7]

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