Combined Spinal Epidural Anesthesia

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Combined Spinal Epidural Anesthesia

  1. 1. Combined Spinal Epidural Anesthesia By Capt Bilal Baig Graded Anesthetist Supervised by Col Manzoor Ahmed Faridi Classified Anesthetist
  2. 2. CASE REPORT <ul><li>PATIENT XYZ </li></ul><ul><li>AGE 25 YRS </li></ul><ul><li>ADDRESS PESHAWAR </li></ul><ul><li>DOA 23.05.07 </li></ul>
  3. 3. Presenting complaints <ul><li>Gestational Amenorrhoea 09 months </li></ul>
  4. 4. Past history <ul><li>Previous 02 C-Sections </li></ul><ul><li>h/o 01 laparotomy for ectopic pregnancy </li></ul>
  5. 5. <ul><li>Drug history </li></ul><ul><li>Family history </li></ul><ul><li>Socioecnomic history not contributory </li></ul>
  6. 6. Obstetrical history <ul><li>G 4 P 3 T 2 A 1 L 2 </li></ul><ul><li>02 male </li></ul><ul><li>Married 06 years </li></ul><ul><li>Normal menstrual cycle </li></ul>
  7. 7. Genral Physical Examination <ul><li>Conscious ,well orientated </li></ul><ul><li>Vital signs </li></ul><ul><ul><li>Pulse 72/min </li></ul></ul><ul><ul><li>BP 110/80mmhg </li></ul></ul><ul><ul><li>Temp Afebrile </li></ul></ul>
  8. 8. Systemic Examination <ul><li>CVS </li></ul><ul><li>CNS not contributory </li></ul><ul><li>Resp </li></ul><ul><li>Abdomen </li></ul><ul><ul><li>FH 36wks </li></ul></ul><ul><ul><li>FHS ++ </li></ul></ul><ul><ul><li>Cephalic Presentation </li></ul></ul>
  9. 9. Investigations <ul><li>Blood CP Hb 9.7g/dl </li></ul><ul><li>Platelets 200x 10 9 /l </li></ul><ul><li>TLC 6.4 x 109/l </li></ul><ul><li>BSR 4.7mmol/l </li></ul><ul><li>Urine RE NAD </li></ul><ul><li>HBsAg & Anti HCV non reactive </li></ul><ul><li>USG abd normal 36 wks pregnancy </li></ul>
  10. 10. <ul><li>Planned for Elective C-Section due to </li></ul><ul><li>Previous 02 C-Sections </li></ul>
  11. 11. Pre-Anesthesia Assesment <ul><li>h/o previous 03 GA </li></ul><ul><li>Severe PONV associated with last GA </li></ul><ul><li>No h/o any systemic illness </li></ul><ul><li>No h/o any bleeding disorder </li></ul><ul><li>No known drug allergy </li></ul><ul><li>Exam of back </li></ul><ul><li>no deformity </li></ul><ul><li>no rash or scaring </li></ul>
  12. 12. Pre-Anesthesia Assesment(contd) <ul><li>No neurological deficit </li></ul><ul><li>No h/o GERD </li></ul><ul><li>ASA 1 </li></ul><ul><li>MP 11 </li></ul>
  13. 13. Anesthetic management <ul><li>Planned for c-section under regional anesthesia with combined spinal epidural technique </li></ul><ul><li>Patient counseled and consented </li></ul><ul><li>Fully explained the whole procedure </li></ul>
  14. 14. Anesthetic management <ul><li>Monitoring </li></ul><ul><li>BP </li></ul><ul><li>Pulse </li></ul><ul><li>SpO2 </li></ul><ul><li>ECG </li></ul>
  15. 15. Anesthetic management <ul><li>Preloaded with ringer lactate 1000ml/IV </li></ul><ul><li>Left uterine displacement </li></ul>
  16. 16. Anesthetic management
  17. 17. Anesthetic management <ul><li>Sitting position </li></ul><ul><li>Cleaned and draped </li></ul>
  18. 18. Anesthetic management <ul><li>Local infiltration </li></ul><ul><li>Epidural space identified by a loss of resistance method with air </li></ul>
  19. 19. Anesthetic management <ul><li>Sub arachnoid's space punctured with a long spinal needle and free flow of CSF confirmed </li></ul>
  20. 20. Anesthetic management <ul><li>3ml 0.50% bupivacaine isobaric solution given </li></ul>
  21. 21. Anesthetic management <ul><li>Epidural cathetar threaded </li></ul><ul><li>Secured with sticking plaster </li></ul>
  22. 22. Anesthetic management <ul><li>Level of the block confirmed </li></ul><ul><li>Operation started </li></ul><ul><li>Vital signs monitored </li></ul><ul><li>Baby delivered </li></ul>
  23. 23. Anesthetic management <ul><li>Good neonatal outcome </li></ul><ul><li>Suction and oxygenation </li></ul>
  24. 24. <ul><li>Patient comfortable </li></ul><ul><li>No narcotics or sedation </li></ul><ul><li>No antiemetic given </li></ul><ul><li>5ml 0.125%bupivacaine before shifting </li></ul>
  25. 25. <ul><li>No post op IV/IM analgesia </li></ul><ul><li>0.125%bupivacaine in 5ml increments SOS </li></ul><ul><li>Remained very comfortable </li></ul><ul><li>No PDPH </li></ul><ul><li>Discharged on 2 nd post Op day </li></ul>
  26. 26. DISCUSSION
  27. 27. Background <ul><li>The first epidural analgesia was done by Corning in 1885 </li></ul><ul><li>Bier , a surgeon was the first to inject cocaine into the spinal space. It was between August 16 and 27, 1898. </li></ul><ul><li>these two compartments were first combined by Soresi in 1937. </li></ul><ul><li>It took another 42 years until Curelaru in 1979 used this combined spinal-epidural anesthesia again </li></ul><ul><li>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. </li></ul>
  28. 28. Anatomy of CSE
  29. 29. Anatomy <ul><li>Spinal cord Begins at foramen magnum </li></ul><ul><li>Extends to sacral hiatus </li></ul><ul><li>Three coverings </li></ul><ul><li>Pia , dura, arachnoid </li></ul>
  30. 30. Anatomy <ul><li>Subarachnoid space </li></ul><ul><li>Between pia and arachnoid </li></ul><ul><li>Cerebral ventricles to S2 </li></ul><ul><li>Contain CSF spinal cord and its nerves &blood vessels </li></ul><ul><li>CSF total 100ml-150ml below foraman magnum 25-40ml </li></ul><ul><li>Spinal cord extends to L3 at birth L1-2 by age 2 </li></ul><ul><li>Tuffiers line corresponds to L4 </li></ul><ul><li>1-2 spaces above a safe margin </li></ul>
  31. 31. Anatomy <ul><li>Epidural space </li></ul><ul><li>Potential space </li></ul><ul><li>Triangular in shape </li></ul><ul><li>Apex posteriorly </li></ul><ul><li>Superiorly foramen magnum </li></ul><ul><li>Inferiorly sacrococcygeal ligament </li></ul><ul><li>Anteriorly posterior longitudinal ligament </li></ul><ul><li>Posteriorly ligamentum flavum </li></ul><ul><li>Laterally dura lamina and pedicles </li></ul><ul><li>Skin subcutaneous tissue supraspinous interspinous ligamentum flavum to reach epidural space </li></ul>
  32. 32. Anatomy <ul><li>Subdural space </li></ul><ul><ul><li>Potential space </li></ul></ul><ul><ul><li>Between dura and arachnoid mater </li></ul></ul><ul><ul><li>Inadvertent injection can cause failure </li></ul></ul>
  33. 33. Anatomy <ul><li>Bony landmarks </li></ul><ul><ul><li>Made of vertebrae(7 cervical,12 thoracic,5 lumbar,4coccygeal) </li></ul></ul><ul><ul><li>Vertebral bodies ,2 pedicles, 2 laminae </li></ul></ul><ul><ul><li>Bodies border anteriorly ,pedicles laterally and laminae posteriorly </li></ul></ul><ul><ul><li>Spinous process horizontal in lumbar more caudal in thoracic </li></ul></ul>
  34. 34. Anatomy <ul><li>Vertebral ligaments </li></ul><ul><ul><li>3 encountered while neuraxial blockade </li></ul></ul><ul><ul><li>Supraspinous </li></ul></ul><ul><ul><li>Interspinous </li></ul></ul><ul><ul><li>Ligamentum flavum </li></ul></ul><ul><ul><ul><li>80% elastin,characteristic feel ,significant resistance </li></ul></ul></ul>
  35. 35. Physiology of Regional Anesthesia <ul><li>Inhibition of sodium channels </li></ul><ul><li>Absorption into systemic circulation terminate action </li></ul><ul><li>Sequence of neural blockade on spinal anesthesia </li></ul><ul><ul><li>Sympathatic block wit vasodilatation </li></ul></ul><ul><ul><li>Loss of pain and temp </li></ul></ul><ul><ul><li>Loss of proprioception </li></ul></ul><ul><ul><li>Loss of pressure </li></ul></ul><ul><ul><li>Motor blockade </li></ul></ul><ul><li>Sympathetic blockade 2 segments higher than sensory </li></ul><ul><li>Motor blockade 2 segments lower than sensory </li></ul><ul><li>Not very apparent during epidural anesthesia and patient can even ambulate </li></ul>
  36. 36. Organ system effects of regional anesthesia <ul><li>Cardiovascular </li></ul><ul><ul><li>Sympathetic block Vasodilatation </li></ul></ul><ul><ul><li>Systemic vascular resistance </li></ul></ul><ul><ul><li>hypotension & tachycardia </li></ul></ul><ul><ul><li>If high enough to block cardiac accelerator fibers at T1-T5 no tachycardia to decrease SVR and collapse </li></ul></ul>
  37. 37. Organ system effects of regional anesthesia <ul><li>Respiratory system </li></ul><ul><ul><li>Lumbar spinal or epidural should no affect </li></ul></ul><ul><ul><li>Even at thoracic levels tidal volume not diminished </li></ul></ul><ul><ul><li>Small decrease in vital capacity due to loss of abdominal and intercostal muscles </li></ul></ul><ul><ul><li>Patients with severe lung disease on accessory muscles high thoracic spinal can cause severe impairment necessitating intubation </li></ul></ul><ul><ul><li>Phrenic nerve (C3/4/5) provide ample oxygenation &ventilation </li></ul></ul>
  38. 38. Organ system effects of regional anesthesia <ul><li>GI system </li></ul><ul><ul><li>Neuroaxial block causes sympathectomy </li></ul></ul><ul><ul><li>Sympathatic outflow originates at T5-L1 </li></ul></ul><ul><ul><li>Unoppesed parasympathetic tone </li></ul></ul><ul><ul><li>Increased peristalisis </li></ul></ul>
  39. 39. Organ system effects of regional anesthesia <ul><li>Urinary system </li></ul><ul><ul><li>Loss of autonomic bladder control &urinary retention </li></ul></ul><ul><ul><li>Bladder should be emptied with a catheter </li></ul></ul>
  40. 40. Organ system effects of regional anesthesia <ul><li>Endocrine system </li></ul><ul><ul><li>Partially block the release of catecholamines ,cortisol & ADH </li></ul></ul>
  41. 41. Advantages of regional anesthesia over general anesthesia <ul><li>Avoidance of airway manipulation </li></ul><ul><li>Decreased stress response </li></ul><ul><li>Less thrombogenesis </li></ul><ul><li>Improved bowel motility </li></ul><ul><li>Less PONV </li></ul><ul><li>Better post op pain control </li></ul><ul><li>Fast turnover </li></ul>
  42. 42. Advantages of epidural over spinal <ul><li>Segmental block can be produced </li></ul><ul><li>Gradual onset so less hemodynamic changes </li></ul><ul><li>Flexibility in density </li></ul><ul><li>No hole in dura so no spinal headache </li></ul>
  43. 43. Disadvantages of epidural compared to spinal <ul><li>Slower induction </li></ul><ul><li>More risk of local anesthetic toxicity </li></ul><ul><li>Less reliable, not dense, patchy </li></ul>
  44. 44. The twin theory <ul><li>Spinal anesthesia is a safe, cost-effective and reliable but have a finite duration of action and many patients will require supplemental analgesia. </li></ul><ul><li>epidural is flexible but has the disadvantage that the effects of the local anesthetics can be delayed </li></ul><ul><li>using the combined spinal-epidural anesthesia there is no more a question of which is better </li></ul><ul><li>Epidural and spinal anesthesia are indeed related to each other </li></ul>
  45. 45. Advantages of CSEA <ul><li>Dense surgical anesthesia via intrathecal route and post op pain control via epidural route </li></ul><ul><li>High risk patients are exposed to a gentler sympathectomy </li></ul><ul><li>Ideal for a &quot;walking&quot; epidural </li></ul><ul><li>Provides immediate pain relief especially for patients that are close to 2nd stage labor </li></ul><ul><li>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 </li></ul><ul><li>Some anesthesiologists feel that the quality of the block is superior due to a small seepage of epidural LA into the subarachnoid space </li></ul>
  46. 46. Techniques <ul><li>The spinal needle through a needle technique </li></ul>
  47. 47. Techniques (cont) <ul><li>The “back eye” technique </li></ul><ul><li>Epidural needle with ports for spinal and epidural. </li></ul>
  48. 48. Techniques (cont) <ul><li>The separate needle technique </li></ul><ul><li>Epidural needle is placed after the spinal placement is completed </li></ul>
  49. 49. Techniques (cont) <ul><li>Eldor needle Technique: an 18g epidural needle and a 22g spinal needle are welded together, both serving as introducers for the respective needles </li></ul>
  50. 50. Technique (cont) <ul><li>Epidural catheter is placed first and test dosed </li></ul><ul><li>Possibility of damaging epidural catheter </li></ul><ul><li>More time consuming </li></ul><ul><li>Rarely used these days </li></ul>
  51. 51. Indications <ul><li>&quot;to paint the fence&quot; from both its sides </li></ul><ul><ul><li>hip replacement surgery (28.2%) </li></ul></ul><ul><ul><li>hysterectomy (19%) </li></ul></ul><ul><ul><li>knee surgery (14.4%), </li></ul></ul><ul><ul><li>Cesarean section (14%), </li></ul></ul><ul><ul><li>femur fracture in elderly patients (7.2%) </li></ul></ul><ul><ul><li>prostatectomy (5.6%) </li></ul></ul><ul><ul><li>labor analgesia </li></ul></ul><ul><ul><li>high abdominal and even thoracic operations by the adjuvant use of an endotracheal tube ventilation </li></ul></ul>
  52. 52. Pre-requisites <ul><li>Complete blood picture </li></ul><ul><li>should not be given if platelet count < 50 </li></ul><ul><li>be careful if between 50 to 99 </li></ul><ul><li>Coagulation profile </li></ul><ul><li>Examination of the back </li></ul><ul><li>Informed consent with full explanation of procedure and possible complications </li></ul><ul><li>Detailed history and examination </li></ul><ul><li>bleeding abnormality neurological deficits </li></ul><ul><li>Access to fetal monitoring </li></ul>
  53. 53. Contraindications <ul><li>Absolute </li></ul><ul><ul><li>Patient refusal </li></ul></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>Uncorrected hypovolemia </li></ul></ul><ul><ul><li>Coagulopathy </li></ul></ul><ul><li>Relative </li></ul><ul><ul><li>Elevated ICP </li></ul></ul><ul><ul><li>Prior back injury with deficit </li></ul></ul><ul><ul><li>Progressive neurological disease like multiple sclerosis </li></ul></ul><ul><ul><li>Chronic back pain </li></ul></ul><ul><ul><li>Localized infection at injection site </li></ul></ul>
  54. 54. Problems <ul><li>Flow of local anesthetic into the subarachnoid space through the perforation produced by the spinal needle </li></ul><ul><li>Inability to perform the epidural catheter test dose due to the fact that the epidural catheter is inserted after the subarachnoid local anesthetic injection </li></ul><ul><li>Epidural catheter malposition in the subarachnoid space or intravascular with a danger of total spinal </li></ul><ul><li>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 </li></ul><ul><li>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. </li></ul><ul><li>Epidural needle or catheter unintentional dural puncture </li></ul>
  55. 55. Complications <ul><li>Technique related: </li></ul><ul><ul><li>Headache - Post-Dural Puncture Headache </li></ul></ul><ul><ul><li>Back pain </li></ul></ul><ul><ul><li>Injury to nerves </li></ul></ul><ul><ul><li>Permanent injury to the spinal cord </li></ul></ul><ul><ul><li>Epidural hematomas </li></ul></ul><ul><li>Local anesthetic dose related: </li></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Shivering </li></ul></ul><ul><ul><li>Bladder distension </li></ul></ul><ul><ul><li>Supine Hypotension </li></ul></ul><ul><ul><li>Leg numbness and weakness </li></ul></ul>

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