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Combined SpinalEpidural Anesthesia CSE


... appropriate interspace then using the epidural needle as a guide or introducer ... of an epidural needle at the selected interspace (usually L3-4 or L4-5) ... – PowerPoint PPT presentation

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Title: Combined SpinalEpidural Anesthesia CSE

Combined Spinal/Epidural Anesthesia (CSE)
  • Vincent Conte, MD
  • Associate Clinical Professor
  • Nurse Anesthesia Program
  • FIU College of Nursing

  • First described in 1937
  • This technique has risen in popularity over the
    last 15 years
  • Currently being used for Orthopedic, Urologic,
    and Gynecologic surgeries and for providing
    post-op pain relief
  • Gained much favor in Obstetrics for providing
    ANALGESIA ANESTHESIA for labor, delivery or for

  • CSE Anesthesia Analgesia offers the advantages
    of both techniques
  • It can be used in any situation where a spinal or
    epidural is planned
  • It offers the Quick onset of a spinal with the
    Flexibility of an epidural catheter for
    prolonged procedures and/or post-op pain relief

History Development
  • In 1937, Soresi described the sequential
    injection of LA, first into the epidural space
    then into the subarachnoid space using the same
    small gauge spinal needle
  • His experience using this technique in over 200
    patients led him to report that by combining
    the two methods many of the disadvantages of both
    methods are eliminated and their advantages are
    enhanced to an almost incredible degree.

History Development
  • In 1979 Curelaru provided CSE to more than 150
    patients using a two-puncture technique
  • First he placed an epidural catheter, then
    performed the subarachnoid injection one or two
    interspaces lower

History Development
  • Advantages of the technique included the
    possibility of obtaining a high quality
    conduction anesthesia, virtually unlimited in
    time, minimal toxicity and the absence of
    postoperative pulmonary complications.
  • Disadvantages included the need for two
    vertebral punctures, a longer time for the onset
    of anesthesia and difficulty finding the
    subarachnoid space after catheterization of the
    epidural space.

History Development
  • In 1982 Coates, Mumtaz, and colleagues reported
    using a single space technique in which a long
    spinal needle was inserted through the epidural
    needle to provide the spinal component of the CSE
  • Coates reported that the technique was simple,
    reliable and quick to perform.
  • He was however, concerned with the possible
    passage of the epidural catheter through the hole
    in the dura and the possible subarachnoid
    injection of the epidural medication with a
    resultant high block or total spinal

History Development
  • They were also concerned with the creation of
    metal particles by the two needles rubbing
    together and these particles being introduced
    into either or both of the subarachnoid and/or
    the epidural spaces
  • This led to the design of a type of needle that
    has TWO channels in one needle with one dedicated
    for the epidural cath and the other dedicated for
    the spinal needle

History Development
  • The double channel needle proved to be fairly
    large in diameter and was leading to significant
    tissue trauma and backache post procedure
  • Other needles began to be developed, including
    the ones used today
  • The most common one used today is a modified
    Tuohy needle with a Back eye located at the
    bend of the needle (see photo)

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History Development
  • The other needle used today is a straight
    beveled, blunt tipped epidural needle, but there
    is a higher incidence of inadvertent dural
    puncture during placement since it is NOT rounded
    like the Tuohy
  • About 70 of the kits have the modified Tuohy and
    the other 30 have the straight beveled blunted
    epidural needle

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  • TWO-LEVEL Technique
  • The epidural catheter is inserted FIRST and
    tested so placement is confirmed
  • Then the spinal is done at one or two interspaces
    below the level of the epidural
  • ADVANTAGE Able to test Epidural cath prior to
    spinal injection
  • DISADVANTAGE Trauma and discomfort from
    multilevel insertion

  • First used in 1982, the needle-through-needle
    technique involves inserting an epidural needle
    at the appropriate interspace then using the
    epidural needle as a guide or introducer for the
    spinal needle
  • A small 25 or 27gauge spinal needle can be used
    since the epidural needle is its guide and the
    tissue has already been penetrated by the first

Single Level Insertion
  • ADVANTAGE Single level insertion associated with
    less tissue trauma, backache and associated
  • DISADVANTAGE Inability to be able to adequately
    test the epidural catheter position and function
    with a pre-existing spinal block since the spinal
    part of the procedure must go first

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Single Level Insertion
  • Once your epidural catheter is placed, ANY FLUID
    aspirated from it must be assessed to see if it
    is CSF
  • CSF is warm to the touch if allowed to drip on
    your forearm
  • CSF will form a precipitate if mixed with an
    equal volume of Sodium Thiopental
  • ANY injection via the catheter must ONLY BE DONE
    after careful and diligent test aspirations, and
    you need to aspirate every 3-5cc while giving
    your epidural doses

Single Level Insertion
  • Insertion of the epidural cath through your
    spinal hole must be avoided and detected at all
    costs because the effect of injection of your
    epidural dose into the CSF can lead to a total
    spinal and leave you with a big pile of ! to
    deal with
  • Once the spinal is done, REASSESS your epidural
    needle placement to re-confirm LOR and
    appropriate needle tip placement

Single Level Technique
  • This is one situation in which your epidural dose
    should be given via the catheter rather than the
  • Your needle is right in front of the hole you
    just made in the dura so any positive pressure of
    LA through the needle may go right through the
    hole and become subarachnoid and again lead to a
    high block or total spinal

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Sequential Technique
  • Rawal described a single level sequential
    technique that was designed to minimize the
    hypotensive effects of the spinal portion of the
  • An epidural needle is placed at the selected IVS
    and a low dose (7.5mg of hyperbaric Bupivicaine)
    of spinal anesthetic is given

Sequential Technique
  • The epidural catheter is placed as quickly as
    possible and the patient is placed supine again,
    as soon as possible
  • Once the spinal dose has set in and the level is
    determined, the catheter is used to titrate the
    dose higher (1.5 2cc per unblocked segment)
    until the desired effect is obtained

Sequential Technique
  • ADVANTAGE minimizes the hypotensive effect of
    the spinal component
  • DISADVANTAGE(S) Time consuming and you are
    really only using each technique to half its
    potential and risking all the possible side
    effects and complications
  • Better to use either one or the other technique
    alone and use it to its fullest potential

Agents Used
  • Agents used for spinal component
  • Lidocaine 5 hyperbaric
  • Bupivicaine 0.75 hyperbaric
  • Agents used for Epidural component
  • Lidocaine 2 w or w/o epi
  • Bupivicaine 0.25-0.5 plain
  • Chlorprocaine 2-3 plain

Current Techniques and Uses
  • Although the CSE technique can be used in any
    type of surgical procedure in which a spinal or
    epidural would be acceptable, the CSE technique
    is particularly well suited for providing
    analgesia and anesthesia to Obstetric patients
  • It is the main technique employed in the
    Walking epidural

Current Technique
  • The CSE technique offers several advantages over
    conventional Epidural analgesia and anesthesia
  • Rapid onset of the intrathecal component for
    women who are in the later stages of labor and
    who are in significant pain
  • The use of Intrathecal Opiods in early labor
    provides pain relief with possible minimal to
    absent motor block and allows the patient to

Current Technique
  • The CSE technique involves the placement of an
    epidural needle at the selected interspace
    (usually L3-4 or L4-5)
  • Once the epidural needle is placed, it is
    followed by the passage of the spinal needle in
    the needle-through-needle technique
  • Usually at this point Fentanyl 25-50mcg is
    injected intrathecally with or w/o a small dose
    of Bupivicaine (2.5mg) or preservative-free NS

Current Technique
  • The epidural catheter is then passed and the
    epidural needle is withdrawn and the catheter is
    secured in place by 2 silk tape or Hypo-fix
    tape (paper tape in tape-allergic patients)
  • The epidural catheter can be activated at any
    time that supplemental analgesia or anesthesia
    are needed
  • Usually the catheter is activated using
    0.125-0.25 Bupivicaine followed by initiation of
    an infusion of 0.0625-0.125 Bupivicaine at
    10-12cc/hr (w or w/o opioids)

Current Technique
  • Should the need arise to convert to a C-section,
    after careful aspiration of the catheter, a test
    dose of 3cc of 1.5 Lidocaine W/epi is given
  • After a negative test dose, incremental doses of
    Lidocaine 2, Bupivicaine 0.5 or Chlorprocaine
    3 can be given to establish a sufficient level
    of surgical anesthesia

Current Technique
  • Despite the utility and flexibility of the CSE
    technique, several concerns related to its use
  • 1) The ability of the patient to SAFELY ambulate
    following intrathecal opioid administration
    There is a tremendous individual variation in the
    responses experienced by patients ranging from no
    changes in motor function to a significant level
    of weakness sufficient to keep them in bed for
    their entire labor. The mechanism is not
    completely understood but a significant part
    relates to sudden hypotension following
    intrathecal opioid administration (NOT Good to
    have Pregnant women falling down in the hallways
    while in labor!!!)

Current Technique
  • 2) Concerns about possible complications
  • Failure to obtain a Subarachnoid block
  • (needle too short)
  • Catheter Migration (through dural puncture hole)
  • Metallic Particles (needle through needle)
  • Post-dural Puncture Headache
  • Infection (higher incidence than spinal or
    epidurals alone)
  • Neurologic Injury due to masking of parasthesias
    by the subarachnoid block caused by the epidural

  • There are advantages and disadvantages of using
  • The fad or selling point of a walking
    epidural is loosing ground and is being used less
    and less frequently due to liability issues
  • You expose yourself to complications from BOTH
    procedures while really never utilizing one
    technique fully probably better to use one or
    the other to its full extent