Combined Spinal-Epidural Technique
Joanne Ramjohn (modified by M.Froelich) (11/03):
Indications:
C-sections and labor epidurals. This technique can be used in any surgery where completion time may be extended. It is also useful for dense surgical anesthesia via intrathecal route and post op pain control via epidural route.
Techniques:
Tuohy needle is positioned in epidural space and the spinal needle is advanced through it. Either the spinal needle follows the contour of the epidural needle and exits at a slight angle or the spinal needle exits the epidural needle through a hole in the tip of the epidural needle (back hole technique)
Alternative approaches (rare):
a)TA needle pair- an 18g epidural needle and a 22g spinal needle are welded together, both serving as introducers for the respective needles (Eldor needle).
b)Two separate segmental interspaces are used- one for spinal and the other for epidural.
Drugs:
- (a) CSE for labor:
1.0-1.5 mL of isobaric (epidural) 0.25% bupivacaine plus 15 mcg fentanyl (or 5 mcg sufentatil). Remember that the pain intensity increases as labor advances. Giving a narcotic dose only is adequate for early labor but not for advanced labor. The continuous infusion may be started after the intrathecal dose has been administered (e.g. 0.125 % bupivacaine at 6 mL/hr), repeated patient checks are necessary.
- (b) Standard CSE for surgery
Intrathecal----bupivicaine 0.5%-0.75% 7.5-15mg and fentanyl 20-25 mcg or sufentanil 3-5mcg
Epidural ----bupivicaine 0.25%-0.5% 10-40mg and fentanyl 20-25mcg or sufentanil 5-10mcg
- (c) Sequential CSE for surgery
Intrathecal----bupivicaine 0.5% hyperbaric 5-12.5mg and fentanyl 20-25mcg or suf 3-5mcg
Epidural ----bupivicaine 0.2%-0.5% 10-50mg and fentanyl 20-25mcg or suf 5-10mcg.
The standard CSE technique (for surgery) uses the intrathecal dose for primary anesthesia and the epidural dose for unexpected prolongation of surgery or for post op pain control.
The sequential technique is done in a seated position and used for a level of T8-9 --S5. The patient is then placed supine and a top up dose of 1-1.5cc of epidural anesthetic is used for each additional segmental block needed.
Advantages:
1)High risk patients are exposed to a gentler sympathectomy
2)Ideal for a "walking" epidural
3)Provides immediate pain relief especially for patients that are close to 2nd stage labor
4)Decreased risk of a post dural puncture headache. This is secondary to using a Tuohy introducer resulting in fewer sticks, decreased dura leak from pressure of epidural dose and the use of epidural opioids.
5) some anesthesiologists feel that the quality of the block is superior due to a small seepage of epidural LA into the subarachnoid space.
Test dose:
All epidural catheters need to be tested. This is also true for epidural catheters placed as part of a CSE.
