title: Persistent hiccups associated with epidural ropivacaine in a newborn.
abstract: OBJECTIVE
  To report a case of persistent hiccups associated with epidural ropivacaine in a newborn infant.
  
  
  METHODS
  A term female infant (3.05 kg) received epidural ropivacaine for pain control during and after an operative procedure to correct a tracheoesophageal fistula. Three intermittent doses of ropivacaine were administered during the operative period (total dose 2.29 mg/kg) followed by a continuous epidural (caudal) infusion (0.1% ropivacaine; initial dose 0.23 mg/kg/h plus fentanyl 0.46 μg/kg/h). The infant was extubated in the recovery area and transferred to the intensive care unit. Within hours of transfer, she developed persistent hiccups. The epidural infusion was titrated for pain control, up to 0.32 mg/kg/h (ropivacaine). The hiccup frequency increased to every 10-30 seconds, with the patient appearing hypotonic with lip trembling and intermittent tongue fasciculation. An electroencephalogram did not show any epileptiform activity or focal features consistent with seizure activity. The epidural infusion was reduced to 0.26 mg/kg/h (ropivacaine), with dramatic improvement in hiccups and tone. The infusion was discontinued and complete resolution of hiccups was observed.
  
  
  CONCLUSIONS
  Ropivacaine is commonly used for infiltration anesthesia and peripheral and epidural block anesthesia. Use of the Naranjo probability scale determined that our patient's hiccups were probably caused by ropivacaine. To our knowledge, this is the first report of persistent hiccups associated with epidural ropivacaine.
  
  
  CONCLUSIONS
  Clinicians should consider the potential of neurotoxicity, manifested as persistent hiccups, when epidural ropivacaine is administered to young infants.
authors.affiliation: Pediatric Intensive Care Unit, Section of Critical Care Medicine, The Children's Hospital, Aurora, CO, USA. bagdure.dayanand@tchden.org
authors.forename: Dayanand N
authors.initials: DN
authors.lastname: Bagdure
authors.forename: Pamela D
authors.initials: PD
authors.lastname: Reiter
authors.forename: Girija R
authors.initials: GR
authors.lastname: Bhoite
authors.forename: Emily L
authors.initials: EL
authors.lastname: Dobyns
authors.forename: Pramote
authors.initials: P
authors.lastname: Laoprasert
mesh_terms: D000577:Amides / Q000008:administration & dosage / Q000009:adverse effects*; D015360:Analgesia, Epidural / Q000009:adverse effects / Q000379:methods; D000779:Anesthetics, Local / Q000008:administration & dosage / Q000009:adverse effects*; D005260:Female; D006606:Hiccup / Q000139:chemically induced*; D006801:Humans; D007231:Infant, Newborn; D020258:Neurotoxicity Syndromes / Q000209:etiology* / Q000503:physiopathology; D000077212:Ropivacaine; D014138:Tracheoesophageal Fistula / Q000601:surgery
chemical_list: D000577:Amides; D000779:Anesthetics, Local; D000077212:Ropivacaine