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JA Clin Rep
JA Clin Rep
JA Clinical Reports
2363-9024
Springer Berlin Heidelberg Berlin/Heidelberg

39230836
727
10.1186/s40981-024-00727-y
Letter to the Editor
Hiccups during general anesthesia with remimazolam
http://orcid.org/0000-0001-5169-4418
Mizutani Koh youshookme40@yahoo.co.jp

1
Tsuchiya Masahiko 2
1 grid.440401.5 0000 0004 0604 6990 Department of Anesthesia, Chibune Hospital, 3-2-39 Fukumachi, Nishiyodogawa-Ku, Osaka, 555-0034 Japan
2 https://ror.org/05gn4hz56 grid.415384.f 0000 0004 0377 9910 Department of Anesthesia, Kishiwada Tokushukai Hospital, 4-27-1, Kamoricho, Kishiwada, 596-0042 Japan
4 9 2024
4 9 2024
12 2024
10 5531 5 2024
3 7 2024
6 7 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by/4.0/ Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
issue-copyright-statement© The Japanese Society of Anesthesiologists 2024
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pmcTo the editor:

We read with interest the reports of hiccups during general anesthesia that were suspected to be caused by remimazolam [1]. Decades ago, we often encountered hiccups during general anesthesia. However, they have become less frequently observed. In retrospect, this change coincided with the introduction of remifentanil. Before remifentanil, the only analgesic administered during general anesthesia was intravenous fentanyl or epidural anesthesia. These agents likely did not inhibit the diaphragmatic stimulation causing hiccups during abdominal surgery or the associated reflex arcs originating in the brainstem [2]. On the other hand, remifentanil’s analgesic effect appears sufficient to inhibit both. In the present case, hiccups occurred despite a sufficient dose of remifentanil and bispectral index (BIS) values between 49 and 60. The reason may be that the hypnosis and reflex inhibition induced by remimazolam, a benzodiazepine, is less profound than that achieved with propofol or volatile inhaled anesthetics [3]. Benzodiazepines, propofol, and volatile inhaled anesthetics act on γ-aminobutyric acid (GABA) receptors, but at different sites of action [4], so their mechanisms of action and BIS values are different [5]. In addition, anesthesia with low BIS values obtained from forebrain electroencephalography does not mean inhibition of brainstem reflexes [6]. Therefore, remimazolam, a benzodiazepine, may not inhibit the hiccup reflex, even though the patient had sufficiently low BIS values. Although the authors concluded that remimazolam may induce hiccups, it is important to note that its weak hypnotic potency and weak reflex inhibition may also play a role.

Since hiccups are unpredictable and infrequent, randomized prospective studies are impractical. Thus, most reports on hiccups during anesthesia are case reports, making it difficult to provide evidence-based conclusions. Consequently, most reports and this letter are based solely on the subjective experiences of their authors.

Acknowledgements

None.

Authors’ contributions

KM: conception and drafting the article. MT: revising it critically for important intellectual content. All authors read and approved the final manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Not applicable.

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Not applicable.

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Not applicable.

Competing interests

The authors declare that they have no competing interests.

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References

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