Combined Spinal/Epidural Anesthesia (CSE)

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

2. 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

3. 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

4. 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.”

5. 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

6. 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.”

7. 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

8. 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

9. 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)

13. 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

15. 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

16. 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 it’s guide and the tissue has already been penetrated by the first needle

17. 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

20. 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

21. 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

22. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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)

32. 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

33. 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!!!)

34. 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

35. 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