Combined spinal and epidural anaesthesia
Encyclopedia
Combined spinal and epidural anaesthesia (CSE) is a regional anaesthetic technique, which combines the benefits of both spinal anaesthesia
and epidural anaesthesia and analgesia. The spinal component gives a rapid onset of a predictable block. The indwelling epidural catheter gives the ability to provide long lasting analgesia and to titrate the dose given to the desired effect.
s, seeking the advantage of using a minimal dose of local anaesthetic in order to have a quicker termination of the spinal anaesthesia, but still having the catheter available in case the patient requires more than the minimal amount of medication to remain comfortable. It was hoped that this technique for caesarean section would yield greater maternal satisfaction with less hypotension and its associated nausea, but it is not clear that the technique has many advantages.
This technique also allows for post operative pain relief via epidural patient controlled anaesthesia. The epidural catheter may be left in place for up to 72 hours if required.
In labouring women, the onset of analgesia is more rapid with CSE compared with epidural analgesia. CSE in labour was formerly thought to enable women to mobilise for longer compared with epidural analgesia, but this is not supported by a recent Cochrane review.
In the UK, the National Institute for Clinical Excellence (September 2007) specifically recommends CSE for women who require rapid onset of analgesia in labour http://www.nice.org.uk/nicemedia/pdf/IPCNICEGuidance.pdf. It further recommends the use of bupivacaine
and fentanyl to establish the block.
Cautions and contraindications are very similar to those for epidural anaesthesia.
Practitioners who make frequent use of the CSE technique for labour analgesia may note unexpected benefits. One example is in the event that the epidural catheter is unintentionally placed into a blood vessel. This requires removal of the catheter and its replacement. With the traditional technique of epidural placement, the patient continues in pain without relief. If the CSE technique has been used, the intrathecal injection of fentanyl results in 60 to 90 minutes of good pain relief. This creates a more pleasant environment in which to replace the errant catheter with a properly sited one.
.
The needle-through-needle technique involves the introduction of a Tuohy needle
(epidural needle) into the epidural space
. The standard technique of loss of resistance to injection may be employed.
A long fine spinal needle (25G) is then introduced via the lumen of the epidural needle and through the dura mater
, into the subarachnoid space
. A small pop is felt as the dura is punctured, and the correct position is confirmed when cerebrospinal fluid
can be seen dripping from the spinal needle.
A small dose of local anaesthetic (e.g. bupivacaine
) is then instilled. An opioid
such as fentanyl may also be given if desired. The spinal needle is then withdrawn and the epidural catheter inserted in the standard manner.
Alternatively, a two-level approach may be undertaken. The epidural space is first located in the standard manner. Then, at another level, a standard spinal is performed. Finally, the epidural catheter is threaded through the Tuohy needle.
Alternatively, several manufacturers produce packs containing both a spinal and an epidural needle which are slightly modified to fit together.
s and complications
of both epidural and spinal anaesthesia.
CSE in labouring women is associated with more pruritis if fentanyl (25μg) is given intrathecally, than low-dose epidural analgesia. However, no difference has been found in the incidence of post dural puncture headache
, requirement for epidural blood patch
or maternal hypotension.
Spinal anaesthesia
Spinal anaesthesia , also called spinal analgesia or sub-arachnoid block , is a form of regional anaesthesia involving injection of a local anaesthetic into the subarachnoid space, generally through a fine needle, usually 9 cm long...
and epidural anaesthesia and analgesia. The spinal component gives a rapid onset of a predictable block. The indwelling epidural catheter gives the ability to provide long lasting analgesia and to titrate the dose given to the desired effect.
Indications
This technique is suitable whenever a rapid onset of analgesia is required but the period of analgesia required exceeds that of a single spinal injection. It may be used for Caesarean sectionCaesarean section
A Caesarean section, is a surgical procedure in which one or more incisions are made through a mother's abdomen and uterus to deliver one or more babies, or, rarely, to remove a dead fetus...
s, seeking the advantage of using a minimal dose of local anaesthetic in order to have a quicker termination of the spinal anaesthesia, but still having the catheter available in case the patient requires more than the minimal amount of medication to remain comfortable. It was hoped that this technique for caesarean section would yield greater maternal satisfaction with less hypotension and its associated nausea, but it is not clear that the technique has many advantages.
This technique also allows for post operative pain relief via epidural patient controlled anaesthesia. The epidural catheter may be left in place for up to 72 hours if required.
In labouring women, the onset of analgesia is more rapid with CSE compared with epidural analgesia. CSE in labour was formerly thought to enable women to mobilise for longer compared with epidural analgesia, but this is not supported by a recent Cochrane review.
In the UK, the National Institute for Clinical Excellence (September 2007) specifically recommends CSE for women who require rapid onset of analgesia in labour http://www.nice.org.uk/nicemedia/pdf/IPCNICEGuidance.pdf. It further recommends the use of bupivacaine
Bupivacaine
Bupivacaine is a local anaesthetic drug belonging to the amino amide group. AstraZeneca commonly markets it under various trade names, including Marcain, Marcaine, Sensorcaine and Vivacaine.-Indications:...
and fentanyl to establish the block.
Cautions and contraindications are very similar to those for epidural anaesthesia.
Practitioners who make frequent use of the CSE technique for labour analgesia may note unexpected benefits. One example is in the event that the epidural catheter is unintentionally placed into a blood vessel. This requires removal of the catheter and its replacement. With the traditional technique of epidural placement, the patient continues in pain without relief. If the CSE technique has been used, the intrathecal injection of fentanyl results in 60 to 90 minutes of good pain relief. This creates a more pleasant environment in which to replace the errant catheter with a properly sited one.
Insertion technique
Combined spinal-epidural anaesthesia is a highly specialised technique which should only be administered by a properly trained anaesthetic practitioner working with full aseptic techniqueAseptic technique
Aseptic technique refers to a procedure that is performed under sterile conditions. This includes medical and laboratory techniques, such as with microbiological cultures. It includes techniques like flame sterilization...
.
The needle-through-needle technique involves the introduction of a Tuohy needle
Tuohy needle
A Tuohy needle is a hollow hypodermic needle, very slightly curved at the end, suitable for inserting epidural catheters.The needle features an anti-coring curve at its tip, as shown in the picture above left.- Epidural needle :...
(epidural needle) into the epidural space
Epidural space
In the spine, the epidural space is the outermost part of the spinal canal. It is the space within the canal lying outside the dura mater...
. The standard technique of loss of resistance to injection may be employed.
A long fine spinal needle (25G) is then introduced via the lumen of the epidural needle and through the dura mater
Dura mater
The dura mater , or dura, is the outermost of the three layers of the meninges surrounding the brain and spinal cord. It is derived from Mesoderm. The other two meningeal layers are the pia mater and the arachnoid mater. The dura surrounds the brain and the spinal cord and is responsible for...
, into the subarachnoid space
Subarachnoid space
In the central nervous system, the subarachnoid cavity is the interval between the arachnoid membrane and pia mater....
. A small pop is felt as the dura is punctured, and the correct position is confirmed when cerebrospinal fluid
Cerebrospinal fluid
Cerebrospinal fluid , Liquor cerebrospinalis, is a clear, colorless, bodily fluid, that occupies the subarachnoid space and the ventricular system around and inside the brain and spinal cord...
can be seen dripping from the spinal needle.
A small dose of local anaesthetic (e.g. bupivacaine
Bupivacaine
Bupivacaine is a local anaesthetic drug belonging to the amino amide group. AstraZeneca commonly markets it under various trade names, including Marcain, Marcaine, Sensorcaine and Vivacaine.-Indications:...
) is then instilled. An opioid
Opioid
An opioid is a psychoactive chemical that works by binding to opioid receptors, which are found principally in the central and peripheral nervous system and the gastrointestinal tract...
such as fentanyl may also be given if desired. The spinal needle is then withdrawn and the epidural catheter inserted in the standard manner.
Alternatively, a two-level approach may be undertaken. The epidural space is first located in the standard manner. Then, at another level, a standard spinal is performed. Finally, the epidural catheter is threaded through the Tuohy needle.
Maintenance technique
When the epidural catheter has been inserted, the techniques of maintenance of block are very similar to those of epidural anaesthesia. The intensity of the block may be adjusted as desired. Large doses of local anaesthetic can produce sufficient anaesthesia for surgery. Alternatively, smaller doses can provide analgesia, e.g. in the postoperative period.Equipment
A standard epidural pack may be used with a standard spinal needle. However, the standard length of a spinal needle (90mm) may be insufficiently long to reach the subarachnoid space through the Tuohy needle. An extra-long needle (e.g. 120mm) may be required.Alternatively, several manufacturers produce packs containing both a spinal and an epidural needle which are slightly modified to fit together.
Complications
This technique shares the contraindicationContraindication
In medicine, a contraindication is a condition or factor that serves as a reason to withhold a certain medical treatment.Some contraindications are absolute, meaning that there are no reasonable circumstances for undertaking a course of action...
s and complications
Complication (medicine)
Complication, in medicine, is an unfavorable evolution of a disease, a health condition or a medical treatment. The disease can become worse in its severity or show a higher number of signs, symptoms or new pathological changes, become widespread throughout the body or affect other organ systems. A...
of both epidural and spinal anaesthesia.
CSE in labouring women is associated with more pruritis if fentanyl (25μg) is given intrathecally, than low-dose epidural analgesia. However, no difference has been found in the incidence of post dural puncture headache
Post dural puncture headache
Post-dural-puncture headache is a complication of puncture of the dura mater...
, requirement for epidural blood patch
Epidural blood patch
An epidural blood patch is a surgical procedure which uses autologous blood in order to close one or many holes in the dura mater of the spinal cord, usually as a result of a previous lumbar puncture. The procedure can be used to relieve post dural puncture headaches caused by lumbar puncture...
or maternal hypotension.