NEW YORK (Reuters Health) – Continuous cervical epidural block might be an effective treatment for intractable hiccups, hints an observational study from South Korea.
“Continuous cervical epidural block is an excellent treatment for intractable hiccups and is effective in preventing recurrence in patients that do not respond to conventional therapies,” Dr. Sang Sik Choi and colleagues from Korea University Guro Hospital, in Seoul, write in the February issue of Medicine.
The team reviewed records of patients with a history of unsuccessful treatments for hiccups from 2008 to 2014, and they included 28 patients with intractable hiccups and a history of unsuccessful medical treatment with gabapentin and baclofen in the study.
The patients were in their mid-fifties, on average, and all were men. At baseline, their hiccups had lasted a mean of 95 days. Gastrointestinal problems were the main cause of their hiccups, including gastritis, gastroesophageal reflux disease (GERD), GERD with gastritis or gastric ulcer, and cholangiocarcinoma.
Other causes included cerebral infarction, cerebral hemorrhage, common cold, chronic laryngitis, and idiopathic hiccups. Problems caused by hiccups included weight loss, dyspnea, and insomnia.
The block was performed with a midline approach at the C7-T1 or T1-T2 intervertebral space with the patient prone, and the catheter was advanced through the needle to the C3-C5 level.
A 6-mL bolus of 0.25% ropivacaine was injected, and 4 mL/hour of ropivacaine was infused continuously through the catheter (0.75% ropivacaine; 45mL ropivacaine in 230 mL normal saline).
After the first block, 11 patients who still had hiccups received a second block. After the second block, two patients who still had the problem received a third block. After the third block, no one had hiccups (cumulative complete remission rates were 61%, 93% and 100%, respectively).
After 48 hiccup-free hours, the catheter was removed. One patient complained of dizziness, which subsided.
Dr. Sandy Christiansen, an assistant professor of anesthesiology and perioperative medicine at the Oregon Health & Science University (OHSU) School of Medicine in Portland, told Reuters Health by email, “While the study is interesting in its approach to intractable hiccups, unfortunately, I do not believe it warrants change in clinical practice without further exploration.”
“The biggest limitation of the study is that while the patients were receiving a bolus/continuous epidural infusion, they were also undergoing other treatments (not defined) designed at addressing the causative factors for the hiccups,” noted Dr. Christiansen, who was not involved in the study. “Thus, it is impossible to say if the epidural infusion was beneficial or if the patient improved because the causative factor(s) of the hiccup was treated.”
Dr. Christiansen suggested a design for a possible future study.
“If the study would be repeated, I would suggest that the researcher consider randomizing the patients into two groups: group 1 gets the epidural bolus/infusion while group 2 gets treatment for their causative factors. It would also be best to have a third group that did not receive treatment, but the authors of the study stated they thought it would be unethical to withhold treatment and perform a randomized placebo-controlled study.”
“Secondly, I have concerns about the safety of the proposed therapy,” she said. “There is no information provided about changes in hemodynamics in these patients while they were receiving the infusion/bolus. While the paper states that there were no adverse events reported, I wonder how many patients required a ‘hemodynamic intervention’ in order to safely complete the study.”
“Ultimately, I think this study tested an interesting idea, but the design of the study does not allow us to conclude whether the epidural bolus/infusion was actually the reason for success and further studies would need to be completed,” Dr. Christiansen concluded.
Dr. Choi did not respond to requests for comment.
SOURCE: http://bit.ly/2ooZf6w
Medicine 2018.
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