Combined Spinal Epidural Anesthesia

Combined Spinal Epidural Anesthesia By Capt Bilal Baig Graded Anesthetist Supervised by Col Manzoor Ahmed Faridi Classified Anesthetist

CASE REPORT
PATIENT XYZ
AGE 25 YRS
ADDRESS PESHAWAR
DOA 23.05.07

Presenting complaints
Gestational Amenorrhoea 09 months

Past history
Previous 02 C-Sections
h/o 01 laparotomy for ectopic pregnancy

Drug history
Family history
Socioecnomic history not contributory

Obstetrical history
G 4 P 3 T 2 A 1 L 2
02 male
Married 06 years
Normal menstrual cycle

Genral Physical Examination
Conscious ,well orientated
Vital signs
Pulse 72/min
BP 110/80mmhg
Temp Afebrile

Systemic Examination
CVS
CNS not contributory
Resp
Abdomen
FH 36wks
FHS ++
Cephalic Presentation

Investigations
Blood CP Hb 9.7g/dl
Platelets 200x 10 9 /l
TLC 6.4 x 109/l
BSR 4.7mmol/l
Urine RE NAD
HBsAg & Anti HCV non reactive
USG abd normal 36 wks pregnancy

Planned for Elective C-Section due to
Previous 02 C-Sections

Pre-Anesthesia Assesment
h/o previous 03 GA
Severe PONV associated with last GA
No h/o any systemic illness
No h/o any bleeding disorder
No known drug allergy
Exam of back
no deformity
no rash or scaring

Pre-Anesthesia Assesment(contd)
No neurological deficit
No h/o GERD
ASA 1
MP 11

Anesthetic management
Planned for c-section under regional anesthesia with combined spinal epidural technique
Patient counseled and consented
Fully explained the whole procedure

Monitoring
BP
Pulse
SpO2
ECG

Preloaded with ringer lactate 1000ml/IV
Left uterine displacement

Sitting position
Cleaned and draped

Local infiltration
Epidural space identified by a loss of resistance method with air

Sub arachnoid's space punctured with a long spinal needle and free flow of CSF confirmed

3ml 0.50% bupivacaine isobaric solution given

Epidural cathetar threaded
Secured with sticking plaster

Level of the block confirmed
Operation started
Vital signs monitored
Baby delivered

Good neonatal outcome
Suction and oxygenation

Patient comfortable
No narcotics or sedation
No antiemetic given
5ml 0.125%bupivacaine before shifting

No post op IV/IM analgesia
0.125%bupivacaine in 5ml increments SOS
Remained very comfortable
No PDPH
Discharged on 2 nd post Op day

DISCUSSION

Background
The first epidural analgesia was done by Corning in 1885
Bier , a surgeon was the first to inject cocaine into the spinal space. It was between August 16 and 27, 1898.
these two compartments were first combined by Soresi in 1937.
It took another 42 years until Curelaru in 1979 used this combined spinal-epidural anesthesia again
Coates from England and Mumtaz, Daz and Kuz from Sweden, in 1982, first described the insertion of a long spinal needle through the epidural needle for performing the combined spinal-epidural anesthesia.

Anatomy of CSE

Anatomy
Spinal cord Begins at foramen magnum
Extends to sacral hiatus
Three coverings
Pia , dura, arachnoid

Anatomy
Subarachnoid space
Between pia and arachnoid
Cerebral ventricles to S2
Contain CSF spinal cord and its nerves &blood vessels
CSF total 100ml-150ml below foraman magnum 25-40ml
Spinal cord extends to L3 at birth L1-2 by age 2
Tuffiers line corresponds to L4
1-2 spaces above a safe margin

Anatomy
Epidural space
Potential space
Triangular in shape
Apex posteriorly
Superiorly foramen magnum
Inferiorly sacrococcygeal ligament
Anteriorly posterior longitudinal ligament
Posteriorly ligamentum flavum
Laterally dura lamina and pedicles
Skin subcutaneous tissue supraspinous interspinous ligamentum flavum to reach epidural space

Anatomy
Subdural space
Potential space
Between dura and arachnoid mater
Inadvertent injection can cause failure

Anatomy
Bony landmarks
Made of vertebrae(7 cervical,12 thoracic,5 lumbar,4coccygeal)
Vertebral bodies ,2 pedicles, 2 laminae
Bodies border anteriorly ,pedicles laterally and laminae posteriorly
Spinous process horizontal in lumbar more caudal in thoracic

Anatomy
Vertebral ligaments
3 encountered while neuraxial blockade
Supraspinous
Interspinous
Ligamentum flavum
80% elastin,characteristic feel ,significant resistance

Physiology of Regional Anesthesia
Inhibition of sodium channels
Absorption into systemic circulation terminate action
Sequence of neural blockade on spinal anesthesia
Sympathatic block wit vasodilatation
Loss of pain and temp
Loss of proprioception
Loss of pressure
Motor blockade
Sympathetic blockade 2 segments higher than sensory
Motor blockade 2 segments lower than sensory
Not very apparent during epidural anesthesia and patient can even ambulate

Organ system effects of regional anesthesia
Cardiovascular
Sympathetic block Vasodilatation
Systemic vascular resistance
hypotension & tachycardia
If high enough to block cardiac accelerator fibers at T1-T5 no tachycardia to decrease SVR and collapse

Respiratory system
Lumbar spinal or epidural should no affect
Even at thoracic levels tidal volume not diminished
Small decrease in vital capacity due to loss of abdominal and intercostal muscles
Patients with severe lung disease on accessory muscles high thoracic spinal can cause severe impairment necessitating intubation
Phrenic nerve (C3/4/5) provide ample oxygenation &ventilation

GI system
Neuroaxial block causes sympathectomy
Sympathatic outflow originates at T5-L1
Unoppesed parasympathetic tone
Increased peristalisis

Urinary system
Loss of autonomic bladder control &urinary retention
Bladder should be emptied with a catheter

Endocrine system
Partially block the release of catecholamines ,cortisol & ADH

Advantages of regional anesthesia over general anesthesia
Avoidance of airway manipulation
Decreased stress response
Less thrombogenesis
Improved bowel motility
Less PONV
Better post op pain control
Fast turnover

Advantages of epidural over spinal
Segmental block can be produced
Gradual onset so less hemodynamic changes
Flexibility in density
No hole in dura so no spinal headache

Disadvantages of epidural compared to spinal
Slower induction
More risk of local anesthetic toxicity
Less reliable, not dense, patchy

The twin theory
Spinal anesthesia is a safe, cost-effective and reliable but have a finite duration of action and many patients will require supplemental analgesia.
epidural is flexible but has the disadvantage that the effects of the local anesthetics can be delayed
using the combined spinal-epidural anesthesia there is no more a question of which is better
Epidural and spinal anesthesia are indeed related to each other

Advantages of CSEA
Dense surgical anesthesia via intrathecal route and post op pain control via epidural route
High risk patients are exposed to a gentler sympathectomy
Ideal for a "walking" epidural
Provides immediate pain relief especially for patients that are close to 2nd stage labor
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
Some anesthesiologists feel that the quality of the block is superior due to a small seepage of epidural LA into the subarachnoid space

Techniques
The spinal needle through a needle technique

Techniques (cont)
The “back eye” technique
Epidural needle with ports for spinal and epidural.

Techniques (cont)
The separate needle technique
Epidural needle is placed after the spinal placement is completed

Techniques (cont)
Eldor needle Technique: an 18g epidural needle and a 22g spinal needle are welded together, both serving as introducers for the respective needles

Technique (cont)
Epidural catheter is placed first and test dosed
Possibility of damaging epidural catheter
More time consuming
Rarely used these days

Indications
"to paint the fence" from both its sides
hip replacement surgery (28.2%)
hysterectomy (19%)
knee surgery (14.4%),
Cesarean section (14%),
femur fracture in elderly patients (7.2%)
prostatectomy (5.6%)
labor analgesia
high abdominal and even thoracic operations by the adjuvant use of an endotracheal tube ventilation

Pre-requisites
Complete blood picture
should not be given if platelet count < 50
be careful if between 50 to 99
Coagulation profile
Examination of the back
Informed consent with full explanation of procedure and possible complications
Detailed history and examination
bleeding abnormality neurological deficits
Access to fetal monitoring

Contraindications
Absolute
Patient refusal
Sepsis
Uncorrected hypovolemia
Coagulopathy
Relative
Elevated ICP
Prior back injury with deficit
Progressive neurological disease like multiple sclerosis
Chronic back pain
Localized infection at injection site

Problems
Flow of local anesthetic into the subarachnoid space through the perforation produced by the spinal needle
Inability to perform the epidural catheter test dose due to the fact that the epidural catheter is inserted after the subarachnoid local anesthetic injection
Epidural catheter malposition in the subarachnoid space or intravascular with a danger of total spinal
Insertion of the spinal needle through the bent tip of the epidural needle in the needle-through-needle technique there is friction that produces metallic microparticles that can be introduced further into the epidural space by the epidural catheter insertion
Delay in epidural catheter threading in the needle-through-needle technique there is a partial spinal anesthesia while using the hyperbaric anesthetic solution with the need to supplement it further through the epidural route.
Epidural needle or catheter unintentional dural puncture

Complications
Technique related:
Headache - Post-Dural Puncture Headache
Back pain
Injury to nerves
Permanent injury to the spinal cord
Epidural hematomas
Local anesthetic dose related:
Hypotension
Shivering
Bladder distension
Supine Hypotension
Leg numbness and weakness

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Combined Spinal Epidural Anesthesia

by bilal76 on Dec 30, 2008

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Combined Spinal Epidural Anesthesia — Presentation Transcript