Download Combined spinal-epidural anesthesia

COMBINED SPINALEPIDURAL ANESTHESIA
H.MOEINI
ANESTHESIOLOGIST
COMBINED SPINAL-EPIDURAL ANESTHESIA
• first described in 1937 CSE was first described in 1937 by Soresi
• but has subsequently been modified over the past 30 years
• Curelaru performed the first combined spinal anesthesia and
catheter-based epidural anaesthesia in 1979
• the CSE technique is now seeing increasing popularity
COMBINED SPINAL-EPIDURAL ANESTHESIA
COMBINED SPINAL-EPIDURAL ANESTHESIA
• A CSE allows flexibility in a number of clinical settings because the
more rapid onset of spinal block compared with epidural
anesthesia allows the operative procedure to begin earlier,
whereas the epidural catheter still provides both effective
postoperative analgesia and allows anesthesia to be extended as
the spinal resolves
COMBINED SPINAL-EPIDURAL ANESTHESIA
• This is particularly useful during labor, where opioid and a small
dose of local anesthetic may be injected through a small spinal
needle to provide rapid analgesia, whereas the epidural catheter
can be used thereafter for both analgesia and surgical anesthesia if
an operative delivery becomes necessary
CSE (COMBINED SPINAL AND EPIDURAL ANESTHESIA)
• Spinal
• fast onset
• high success rate
• excellent muscle relaxation
• low toxicity
• Epidural
–
–
–
–
high flexibility
good controllability
prolonged anesthesica
postoperative pain control
COMBINED SPINAL-EPIDURAL ANESTHESIA
• Another significant advantage of CSE in general is:
the ability to use a low dose of intrathecal local
anesthetic, with the knowledge that the epidural catheter
may be used to extend the block if necessary
COMBINED SPINAL-EPIDURAL ANESTHESIA
• The addition of either local anesthetic or saline
alone to the epidural space via the catheter
compresses the dural sac and increases the
block height
• Epidural volume extension (EVE)
and has been shown in cesarean delivery to
provide a comparable sensory block to larger
doses of intrathecal local anesthetic (with no
epidural volume extension) but with significantly
faster motor recovery
COMBINED SPINAL-EPIDURAL ANESTHESIA
• This sequential technique also provides
•
greater hemodynamic stability for high-risk patients
• using a lower initial mass of drug for spinal anesthetic,
• with subsequent gradual extension of the block if necessary using the
epidural
COMBINED SPINAL-EPIDURAL ANESTHESIA
TECHNIQUE
• The CSE technique most commonly involves
placement of the epidural needle first, followed by
either a “needle through needle” technique to
reach the subarachnoid space or an altogether
separate spinal needle insertion at either the same
or different interspace
COMBINED SPINAL-EPIDURAL ANESTHESIA
TECHNIQUE
• Some but not all studies have demonstrated greater success and lower
failure rates with the separate needle insertion technique
• This method has the potential advantage of being able to confirm that
the epidural catheter is functional before spinal anesthesia is
administered,
• which, although it is time consuming, may be advantageous if the
epidural catheter is to be relied upon for anesthesia when the spinal
component resolves
COMBINED SPINAL-EPIDURAL ANESTHESIA
TECHNIQUE
• Conversely, this method theoretically risks shearing the
epidural catheter that is already in situ
• If a needle-through-needle techniquenis chosen, special
CSE kits are available with long spinal needles, some of
which can be locked in place for the subarachnoid injection
COMBINED SPINAL-EPIDURAL ANESTHESIA
TECHNIQUE
COMPLICATIONS UNIQUE TO COMBINED
SPINAL-EPIDURALS
• The risk of metal toxicity
from abraded spinal
needle particles using
the needle-throughneedle technique has
not been confirmed
ELDOR NEEDLE TECHNIQUE
•
The Eldor needle (1) was first described in 1990.
•
The Eldor needle is a combined spinal-epidural needle which is composed of an 18
gauge epidural needle with a 20 gauge spinal conduit. This is a specialized needle
for the combined spinal-epidural anesthesia.
•
There is no need of long spinal needles. The epidural catheter can be inserted
before the spinal anesthetic injection. The Eldor needle facilitates the insertion of
very small gauge spinal needles through its spinal conduit, so significantly reduces
the incidence of post-dural puncture headache. There is no danger of epidural
catheter protrusion through the dural hole made by the spinal needle. There are no
metallic particles production while the spinal needle passes through the bent
epidural needle tip, as in the needle-through-needle technique. The procedure of
the Eldor needle is quite simple and straightforward. First, the spinal needle is
introduced into the guide needle as far as the distal end of the latter.
•
Then, the now Eldor needle is introduced into the selected intervertebral space and
the epidural space is located using the well-known indicator methods. After that the
epidural catheter is introduced into the epidural space, confirming its position by
the test dose technique. Then, the spinal needle is slowly pushed in to puncture the
dura, until cerebrospinal fluid is obtained. The anesthetic solution is injected
through the spinal needle into the spinal space. Subsequently, the spinal needle is
slowly withdrawn from the guide needle and then the Eldor needle is withdrawn,
leaving the epidural catheter in position in the epidural space.
HUBER NEEDLE TECHNIQUE
• Huber (1), the inventor of the "Tuohy"
epidural needle, also patented in
1953 an hypodermic needle with an
"auxiliary outlet being disposed in transverse
alignment with the channel outlet" (2).
Hanaoka (3) described in 1986 its use in 500
patients. This needle has a very small hole
behind the epidural needle tip ("back eye").
A small gauge spinal needle is inserted
through that hole and punctures the dura.
After withdrawing the spinal needle an
epidural catheter is introduced through the
epidural needle
ESPOCAN CSE NEEDLE (B. BRAUN)
ESPOCAN CSE NEEDLE (B. BRAUN)
HANAOKA (1986)