Combined Spinal/Epidural Anesthesia (CSE)

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Combined Spinal/Epidural Anesthesia (CSE)

• Vincent Conte, MD
• Associate Clinical Professor
• Nurse Anesthesia Program
• FIU College of Nursing

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CSE

• 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
  C-sections

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CSE

• 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

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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.

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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

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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.

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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
  technique
• 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

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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

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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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Techniques

• 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

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Techniques

• SINGLE LEVEL 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
  needle

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Single Level Insertion

• ADVANTAGE Single level insertion associated with
  less tissue trauma, backache and associated
  morbidity
• 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

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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

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Single Level Technique

• This is one situation in which your epidural dose
  should be given via the catheter rather than the
  needle
• 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
  CSE
• An epidural needle is placed at the selected IVS
  and a low dose (7.5mg of hyperbaric Bupivicaine)
  of spinal anesthetic is given

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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

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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

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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

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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

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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
  ambulate

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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

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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)

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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

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Current Technique

• Despite the utility and flexibility of the CSE
  technique, several concerns related to its use
  exist
• 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!!!)

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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
  catheter

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Summary

• There are advantages and disadvantages of using
  CSE
• 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