- Email: [email protected]
Hiccup during weaning from mechanical ventilation: the use of nefopam
Correspondence
afforded them no estimate of the number of patients whose clinical course was positively influenced through the use of EWS at ward level and who, as a result, were not admitted to critical care and did not suffer cardiac arrest or death. Application of the aforementioned composite end point describes final patient outcome, not only as a reflection of a given physiological track and trigger system, but also as a reflection of the nature of the accompanying response algorithm, in addition to all other confounding variations in subsequent clinical management. The work currently underway by Smith and colleagues8 may lead to a greater degree of accuracy in the tracking of physiological parameters through the use of electronic data capture and analysis against a track and trigger algorithm. Although such electronic data capture helps offset human error in the calculation of physiology scores, the work in question is still in its developmental stage and the relevant practical tools are not likely to be available to the majority of healthcare professionals in even the near future. Cuthbertson and Smith also imply that the routine application of physiological track and trigger scoring to all acute patients generates a significant additional workload. Work in the late 1990s confirmed that the application of an aggregate weighted scoring system, with calculation of a total score, took only 30 s to complete ( personal communication). The time taken to complete an aggregate score is now significantly less with improved hard copy ward observation charts incorporating EWS principles in their primary design. Physiological track and trigger can be applied to all acute patients with minimal extra effort for significant potential gain. Routine measurement of ‘basic observations’ to assist in assessment of the severity of a patient’s illness and their clinical progress has been a mainstay of medical and nursing practice for decades. Indeed, it has been a form of implicit physiological tracking but without an explicit ‘trigger’. EWS represents a simple refinement to the completion of basic observations by the assignment of weighted values to time honoured physiological variables according to their degree of deviation from the norm. A total score is then calculated and executive action initiated at an agreed trigger threshold. This trigger threshold is used to assist inexperienced nursing or medical staff in securing immediate, more experienced help. The process enables the implementation of prompt, appropriate customized management plans. These plans are often very simple in the early stages of physiological deterioration but at other times significantly more complex and resource intensive. Such tailored individual patient management clearly represents high-quality care. It is notable that the National Institute for Clinical Excellence (NICE), in its recent (July 2007) definitive guidance on ‘Acutely ill patients in hospital’9 recommend, as a priority, that ‘physiological track and trigger systems should be used to monitor all patients in acute hospital settings’. This priority recommendation echoes an exactly
similar priority recommendation made by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) in 2005 in their publication entitled ‘An Acute Problem’.10 In many acute hospitals in England, the current use of track and trigger scoring systems facilitates the prompt summoning of skilled help to the bedside. We remain convinced that this process enables the ‘high-quality clinical assessment and judgement by appropriately skilled and experienced personnel’, as applauded by Cuthbertson and Smith in their closing comments, to be applied in more timely fashion than might otherwise have been the case. R. J. M. Morgan1* M. M. Wright2 1 Blackpool, UK 2 Great Yarmouth, UK *E-mail: [email protected] 1
Duckitt R, Buxton-Thomas R, Walker J, et al. Worthing physiological scoring system: derivation and validation of a physiological early warning system for medical admissions. An observational, population-based single-centre study. Br J Anaesth 2007; 98: 769–74 2 Cuthbertson BH, Smith GB. A warning on early warning scores! Br J Anaesth 2007; 98: 704 – 6 3 Morgan RJM, Williams F, Wright MM. An early warning scoring system for detecting developing critical illness. Clin Intensive Care 1997; 8: 100 4 Morgan RJM. Outreach critical care—cash for no questions? Correspondence. Br J Anaesth 2003; 90: 699 – 700 5 Buist MD, Moore GE, Bernard SA, et al. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. Br Med J 2002; 324: 387 – 90 6 NHS Modernisation Agency 2003, Progress in Developing Services—Critical Care Outreach 7 Gao H, McDonnell A, Harrison DA, et al. Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward. Intensive Care Med 2007; 33: 667 – 79 8 Smith GB, Prytherch DR, Schmidt P, et al. Hospital wide physiological surveillance—a new approach to the early identification and management of the sick patient. Resuscitation 2006; 71:19 –28 9 NICE clinical guideline 50. Acutely ill patients in hospital. July 2007 10 NCEPOD 2005 Report. An Acute Problem! doi:10.1093/bja/aem286
Hiccup during weaning from mechanical ventilation: the use of nefopam Editor—We report the use of nefopam in two cases with severe hiccup occurring during mechanical ventilation weaning in neurosurgical patients. The first patient was a 46-yr-old male admitted to intensive care after a subarachnoid haemorrhage with early generalized seizures requiring sedation and mechanical ventilation. Neurosurgical clipping was performed 24 h after arrival, and an intracranial
748
Correspondence
pressure (ICP) device and an external ventricular shunt were implanted. I.V. sedation with midazolam and sufentanil and enteral anti-convulsive treatment ( phenytoin 100 mg/8 h) and nimodipine (60 mg/4 h) by nasogastric tube were started. When sedation was stopped 3 days after surgery, the patient developed severe hiccup at a frequency of 20 min21, leading to inefficient mechanical ventilation, including in pressure support mode. Continuous aspiration in the naso-gastric tube was unsuccessful. I.V. treatment with droperidol 0.5 mg and ondansetron 4 mg, used twice, were ineffective. A slow i.v. infusion of nefopam (40 mg in 10 min) decreased hiccup frequency and stopped it in nearly 10 min. Pressure support ventilation (14 mbar) was then possible and efficient. During nefopam treatment, ICP remained stable around 10–15 mm Hg without any seizure whereas heart rate increased from 79 to 90 beats min21. Continuous infusion (100 mg per day) of nefopam was given after the first bolus. Hiccup started again approximately 3 h after the first injection and i.v. administration of 40 mg nefopam was again effective. During the following 2 days, similar episodes were also treated by repeated nefopam 40 mg infusion. Weaning of mechanical ventilation was then possible without complication. The second case was a 45-yr-old male with a severe traumatic brain injury 12 yr earlier resulting in left hemiplegia and chronic hydrocephalus with ventriculo-peritoneal shunt, who was admitted with septic shock secondary to severe pneumonia and peritonitis. The peritonitis was related to small bowel necrosis and surgery for intestinal resection and removal of the peritoneal part of the ventricular shunt was required. An ICP device was placed on the first postoperative day. During the ventilation weaning period, 7 days after surgery, severe hiccup occurred when the pressure support mode was used. Continuous aspiration in the naso-gastric tube and increase in pressure support (up to 20 mbar) were unsuccessful. A slow i.v. infusion of nefopam (40 mg in 10 min) stopped the hiccup in about 10 min. During nefopam treatment, the ICP remained unchanged at 15 mm Hg without any seizure, and heart rate increased from 87 to 101 beats min21. Hiccup started again approximately 8 h after the first injection, requiring another i.v. administration of nefopam, 40 mg, once again rapidly effective. The next day, a similar episode was also treated by another nefopam 40 mg infusion. Weaning of mechanical ventilation was delayed after a ventriculo-atrial shunt was placed surgically. Hiccup has been reported as a frequent problem in stroke patients or those with ventriculo-peritoneal shunt.1 2 The incidence of hiccup in patients undergoing mechanical ventilation is unknown; however, hiccup during mechanical ventilation could lead to patient-ventilator asynchrony. In our patients, the hiccup became an issue for mechanical ventilation weaning. In addition to its analgesic effect, nefopam has been shown to inhibit hiccup in ‘medical’ patients or in the two first postoperative days among ‘surgical’ patients.3 4 The
originality of our case reports is its use during mechanical ventilation weaning. A dose – response effect is likely, as 40 mg bolus worked consistently, whereas continuous infusion did not. We hypothesize that nefopam’s effect was related to its action on serotoninergic receptors and its anticholinergic effects.5 Moreover, as hiccup can be linked with heartbeat,6 the nefopam-induced increase in heart rate (around 10 beats min21 in both cases) could have decreased the hiccup frequency and even stopped it. The use of the nefopam in patients at risk of seizure remains controversial. We did not see seizures or any change in ICP in our two neurosurgical patients. S. Pajot T. Geeraerts* P.-E. Leblanc J. Duranteau D. Benhamou Le Kremlin-Bicetre, France *E-mail: [email protected] 1 Karian JM, Buchheit WA. Intractable hiccup as a complication of ventriculoperitoneal shunt: case report. Neurosurgery 1980; 7: 283–4 2 Kumar A, Dromerick AW. Intractable hiccups during stroke rehabilitation. Arch Phys Med Rehabil 1998; 79: 697– 9 3 Bilotta F, Rosa G. Nefopam for severe hiccups. N Engl J Med 2000; 343: 1973 – 4 4 Bilotta F, Pietropaoli P, Rosa G. Nefopam for refractory postoperative hiccups. Anesth Analg 2001; 93: 1358– 60 5 Girard P, Coppe MC, Verniers D, Pansart Y, Gillardin JM. Role of catecholamines and serotonin receptor subtypes in nefopam-induced antinociception. Pharmacol Res 2006; 54: 195–202 6 Chen BY, Vasilakos K, Boisteanu D, Garma L, Derenne JP, Whitelaw WA. Linkage of hiccup with heartbeat. J Appl Physiol 2000; 88: 2159 – 65 doi:10.1093/bja/aem287
Tracheal intubation with LMA CTrachTM : need for cricoid pressure Editor—Before replacing the intubating laryngeal mask airway (ILMA) with the LMA CTrachTM (CT) in our predefined algorithm for unexpected difficult airway management,1 we assessed CT performance in morbidly obese patients and some with an anticipated difficult airway. We observed that cricoid pressure can be helpful when using the CT. We report two cases of patients with a difficult airway, who despite the CT being optimally placed in the pharynx, required a combination of a Chandy manoeuvre and external force directly applied over the cricoid cartilage to facilitate tracheal intubation. A difficult airway was anticipated in the first patient because of a previous laryngeal tumour (the patient refused awake fibreoptic intubation) and in the second patient upper airway examination revealed a Mallampati grade 3 and 4.0 and 6.5 cm
749
afforded them no estimate of the number of patients whose clinical course was positively influenced through the use of EWS at ward level and who, as a result, were not admitted to critical care and did not suffer cardiac arrest or death. Application of the aforementioned composite end point describes final patient outcome, not only as a reflection of a given physiological track and trigger system, but also as a reflection of the nature of the accompanying response algorithm, in addition to all other confounding variations in subsequent clinical management. The work currently underway by Smith and colleagues8 may lead to a greater degree of accuracy in the tracking of physiological parameters through the use of electronic data capture and analysis against a track and trigger algorithm. Although such electronic data capture helps offset human error in the calculation of physiology scores, the work in question is still in its developmental stage and the relevant practical tools are not likely to be available to the majority of healthcare professionals in even the near future. Cuthbertson and Smith also imply that the routine application of physiological track and trigger scoring to all acute patients generates a significant additional workload. Work in the late 1990s confirmed that the application of an aggregate weighted scoring system, with calculation of a total score, took only 30 s to complete ( personal communication). The time taken to complete an aggregate score is now significantly less with improved hard copy ward observation charts incorporating EWS principles in their primary design. Physiological track and trigger can be applied to all acute patients with minimal extra effort for significant potential gain. Routine measurement of ‘basic observations’ to assist in assessment of the severity of a patient’s illness and their clinical progress has been a mainstay of medical and nursing practice for decades. Indeed, it has been a form of implicit physiological tracking but without an explicit ‘trigger’. EWS represents a simple refinement to the completion of basic observations by the assignment of weighted values to time honoured physiological variables according to their degree of deviation from the norm. A total score is then calculated and executive action initiated at an agreed trigger threshold. This trigger threshold is used to assist inexperienced nursing or medical staff in securing immediate, more experienced help. The process enables the implementation of prompt, appropriate customized management plans. These plans are often very simple in the early stages of physiological deterioration but at other times significantly more complex and resource intensive. Such tailored individual patient management clearly represents high-quality care. It is notable that the National Institute for Clinical Excellence (NICE), in its recent (July 2007) definitive guidance on ‘Acutely ill patients in hospital’9 recommend, as a priority, that ‘physiological track and trigger systems should be used to monitor all patients in acute hospital settings’. This priority recommendation echoes an exactly
similar priority recommendation made by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) in 2005 in their publication entitled ‘An Acute Problem’.10 In many acute hospitals in England, the current use of track and trigger scoring systems facilitates the prompt summoning of skilled help to the bedside. We remain convinced that this process enables the ‘high-quality clinical assessment and judgement by appropriately skilled and experienced personnel’, as applauded by Cuthbertson and Smith in their closing comments, to be applied in more timely fashion than might otherwise have been the case. R. J. M. Morgan1* M. M. Wright2 1 Blackpool, UK 2 Great Yarmouth, UK *E-mail: [email protected] 1
Duckitt R, Buxton-Thomas R, Walker J, et al. Worthing physiological scoring system: derivation and validation of a physiological early warning system for medical admissions. An observational, population-based single-centre study. Br J Anaesth 2007; 98: 769–74 2 Cuthbertson BH, Smith GB. A warning on early warning scores! Br J Anaesth 2007; 98: 704 – 6 3 Morgan RJM, Williams F, Wright MM. An early warning scoring system for detecting developing critical illness. Clin Intensive Care 1997; 8: 100 4 Morgan RJM. Outreach critical care—cash for no questions? Correspondence. Br J Anaesth 2003; 90: 699 – 700 5 Buist MD, Moore GE, Bernard SA, et al. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. Br Med J 2002; 324: 387 – 90 6 NHS Modernisation Agency 2003, Progress in Developing Services—Critical Care Outreach 7 Gao H, McDonnell A, Harrison DA, et al. Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward. Intensive Care Med 2007; 33: 667 – 79 8 Smith GB, Prytherch DR, Schmidt P, et al. Hospital wide physiological surveillance—a new approach to the early identification and management of the sick patient. Resuscitation 2006; 71:19 –28 9 NICE clinical guideline 50. Acutely ill patients in hospital. July 2007 10 NCEPOD 2005 Report. An Acute Problem! doi:10.1093/bja/aem286
Hiccup during weaning from mechanical ventilation: the use of nefopam Editor—We report the use of nefopam in two cases with severe hiccup occurring during mechanical ventilation weaning in neurosurgical patients. The first patient was a 46-yr-old male admitted to intensive care after a subarachnoid haemorrhage with early generalized seizures requiring sedation and mechanical ventilation. Neurosurgical clipping was performed 24 h after arrival, and an intracranial
748
Correspondence
pressure (ICP) device and an external ventricular shunt were implanted. I.V. sedation with midazolam and sufentanil and enteral anti-convulsive treatment ( phenytoin 100 mg/8 h) and nimodipine (60 mg/4 h) by nasogastric tube were started. When sedation was stopped 3 days after surgery, the patient developed severe hiccup at a frequency of 20 min21, leading to inefficient mechanical ventilation, including in pressure support mode. Continuous aspiration in the naso-gastric tube was unsuccessful. I.V. treatment with droperidol 0.5 mg and ondansetron 4 mg, used twice, were ineffective. A slow i.v. infusion of nefopam (40 mg in 10 min) decreased hiccup frequency and stopped it in nearly 10 min. Pressure support ventilation (14 mbar) was then possible and efficient. During nefopam treatment, ICP remained stable around 10–15 mm Hg without any seizure whereas heart rate increased from 79 to 90 beats min21. Continuous infusion (100 mg per day) of nefopam was given after the first bolus. Hiccup started again approximately 3 h after the first injection and i.v. administration of 40 mg nefopam was again effective. During the following 2 days, similar episodes were also treated by repeated nefopam 40 mg infusion. Weaning of mechanical ventilation was then possible without complication. The second case was a 45-yr-old male with a severe traumatic brain injury 12 yr earlier resulting in left hemiplegia and chronic hydrocephalus with ventriculo-peritoneal shunt, who was admitted with septic shock secondary to severe pneumonia and peritonitis. The peritonitis was related to small bowel necrosis and surgery for intestinal resection and removal of the peritoneal part of the ventricular shunt was required. An ICP device was placed on the first postoperative day. During the ventilation weaning period, 7 days after surgery, severe hiccup occurred when the pressure support mode was used. Continuous aspiration in the naso-gastric tube and increase in pressure support (up to 20 mbar) were unsuccessful. A slow i.v. infusion of nefopam (40 mg in 10 min) stopped the hiccup in about 10 min. During nefopam treatment, the ICP remained unchanged at 15 mm Hg without any seizure, and heart rate increased from 87 to 101 beats min21. Hiccup started again approximately 8 h after the first injection, requiring another i.v. administration of nefopam, 40 mg, once again rapidly effective. The next day, a similar episode was also treated by another nefopam 40 mg infusion. Weaning of mechanical ventilation was delayed after a ventriculo-atrial shunt was placed surgically. Hiccup has been reported as a frequent problem in stroke patients or those with ventriculo-peritoneal shunt.1 2 The incidence of hiccup in patients undergoing mechanical ventilation is unknown; however, hiccup during mechanical ventilation could lead to patient-ventilator asynchrony. In our patients, the hiccup became an issue for mechanical ventilation weaning. In addition to its analgesic effect, nefopam has been shown to inhibit hiccup in ‘medical’ patients or in the two first postoperative days among ‘surgical’ patients.3 4 The
originality of our case reports is its use during mechanical ventilation weaning. A dose – response effect is likely, as 40 mg bolus worked consistently, whereas continuous infusion did not. We hypothesize that nefopam’s effect was related to its action on serotoninergic receptors and its anticholinergic effects.5 Moreover, as hiccup can be linked with heartbeat,6 the nefopam-induced increase in heart rate (around 10 beats min21 in both cases) could have decreased the hiccup frequency and even stopped it. The use of the nefopam in patients at risk of seizure remains controversial. We did not see seizures or any change in ICP in our two neurosurgical patients. S. Pajot T. Geeraerts* P.-E. Leblanc J. Duranteau D. Benhamou Le Kremlin-Bicetre, France *E-mail: [email protected] 1 Karian JM, Buchheit WA. Intractable hiccup as a complication of ventriculoperitoneal shunt: case report. Neurosurgery 1980; 7: 283–4 2 Kumar A, Dromerick AW. Intractable hiccups during stroke rehabilitation. Arch Phys Med Rehabil 1998; 79: 697– 9 3 Bilotta F, Rosa G. Nefopam for severe hiccups. N Engl J Med 2000; 343: 1973 – 4 4 Bilotta F, Pietropaoli P, Rosa G. Nefopam for refractory postoperative hiccups. Anesth Analg 2001; 93: 1358– 60 5 Girard P, Coppe MC, Verniers D, Pansart Y, Gillardin JM. Role of catecholamines and serotonin receptor subtypes in nefopam-induced antinociception. Pharmacol Res 2006; 54: 195–202 6 Chen BY, Vasilakos K, Boisteanu D, Garma L, Derenne JP, Whitelaw WA. Linkage of hiccup with heartbeat. J Appl Physiol 2000; 88: 2159 – 65 doi:10.1093/bja/aem287
Tracheal intubation with LMA CTrachTM : need for cricoid pressure Editor—Before replacing the intubating laryngeal mask airway (ILMA) with the LMA CTrachTM (CT) in our predefined algorithm for unexpected difficult airway management,1 we assessed CT performance in morbidly obese patients and some with an anticipated difficult airway. We observed that cricoid pressure can be helpful when using the CT. We report two cases of patients with a difficult airway, who despite the CT being optimally placed in the pharynx, required a combination of a Chandy manoeuvre and external force directly applied over the cricoid cartilage to facilitate tracheal intubation. A difficult airway was anticipated in the first patient because of a previous laryngeal tumour (the patient refused awake fibreoptic intubation) and in the second patient upper airway examination revealed a Mallampati grade 3 and 4.0 and 6.5 cm
749