Combined spinal-epidural analgesia for labor

Combined spinal-epidural analgesia is a technique that provides rapid-onset, profound epidural analgesia for laboring parturients at almost any stage of labor. The most commonly used technique is a needle-through-needle technique in which the epidural space is identified with an epidural needle, and then a long spinal needle is inserted through the epidural needle and into the cerebrospinal fluid. Intrathecal fentanyl, 15 to 25 μg ± 1 to 2.5 mg of bupivacaine, or 2.5 to 5 μg of sufentanil ± 1 to 2.5 mg of bupivacaine are injected to produce analgesia. The epidural needle is removed and an epidural catheter inserted. Analgesia is maintained by low-dose, patient-controlled epidural analgesia; continuous infusion epidural analgesia; or intermittent top-ups. Pruritus is a very common side effect. Respiratory depression is rare but of great concern. Current literature favors low-dose epidural analgesia in labor as leading to the best patient and obstetric outcomes. Both low-dose conventional epidural analgesia and combined spinal-epidural analgesia produce similar outcomes. The main advantage of combined spinal-epidural analgesia is its predictable profound analgesia in parturients during late labor or when labor is progressing rapidly. Copyright © 2001 by W.B. Saunders Company     

Combined spinal-epidural techniques

The combined spinal-epidural technique has been used increasingly over the last decade. Combined spinal-epidural may achieve rapid onset, profound regional blockade with the facility to modify or prolong the block. A variety of techniques and devices have been proposed. The technique cannot be considered simply as an isolated spinal block followed by an isolated epidural block as combining the techniques may alter each block. This review concentrates on technical and procedural aspects of combined spinal-epidural. Needle-through-needle, separate-needle and combined-needle techniques are described and modifications discussed. Failure rates and causes are reviewed. The problems of performing a spinal block before epidural blockade (potential for unrecognised placement of an epidural catheter, inability to detect paraesthesia during epidural placement, difficulty in testing the epidural, delay in positioning the patient) are described and evaluated. Problems of performing spinal block after epidural blockade (risk of catheter or spinal needle damage) are considered. Mechanisms of modification of spinal blockade by subsequent epidural drug administration are discussed. The review considers choice of technique, needle type, patient positioning and paramedian vs. midline approach. Finally, complications associated with combined spinal-epidural are reviewed.     

A case of extensive block with the combined spinal-epidural technique during labour

The increasing use of combined spinal-epidural analgesia in obstetric practice has arisen from a desire to achieve a rapid onset of analgesia while reducing the intensity of the motor block. Although the procedure has an excellent safety profile, as with any technique there are potential problems. Difficulty in assessing the position of the epidural catheter after establishment of the spinal blockade may lead to an abnormally extensive block when a full-strength local anaesthetic solution is used. We present a case in which the use of 0.5% bupivacaine to top-up the epidural component of a combined spinal-epidural resulted in a total spinal block. The possible causes of this complication are discussed.     

Dural puncture with a 27-gauge Whitacre needle as part of a combined spinal-epidural technique does not improve labor epidural catheter function

BACKGROUND: This prospective, double-blind, randomized study was designed to examine whether the combined spinal-epidural technique without subarachnoid drug administration improved epidural catheter function when compared with the traditional epidural technique. METHODS: After institutional review board approval and informed consent, 251 healthy laboring parturients were randomly assigned to either group DP (combined spinal-epidural technique with 27-gauge Whitacre needle dural puncture but without subarachnoid drug administration) or group NoDP (traditional epidural technique). Patient-controlled epidural analgesia was initiated with 0.11% bupivacaine and 2 microg/ml fentanyl. Top-up doses in 5-ml increments of 0.25% bupivacaine were administered if needed. Previous power analysis revealed that a sample size of 108 patients/group was needed to show a clinically useful reduction of the catheter manipulation rate from 32% to 15%. RESULTS: In groups DP and NoDP, 107 and 123 evaluable patients, respectively, completed the study. Demographics and outcome variables measured, including epidural catheter manipulation and replacement rate, sacral sparing, unilateral block, number of top-up doses, average hourly epidural drug usage, highest sensory blockade level, and labor analgesia quality, were not different between groups. A subgroup of 18 patients without cerebral spinal fluid return during dural puncture had a higher catheter replacement rate than those of groups DP and NoDP, but it did not reach statistical significance. CONCLUSIONS: Dural puncture with a 27-gauge Whitacre needle without subarachnoid drug administration during combined spinal-epidural labor analgesia did not improve epidural labor analgesia quality or reduce catheter manipulation or replacement rate when compared with a traditional epidural technique.     

A comparison of Espocan and Tuohy needles for the combined spinal-epidural technique for labor analgesia

When using the needle-through-needle combined spinal-epidural (CSE) technique for labor analgesia, failure to obtain cerebrospinal fluid (CSF), paresthesias, and intrathecal or intravascular migration of the catheter are of concern. Epidural needles with spinal needle apertures, such as the back-hole Espocan (ES) needles, are available and may reduce these risks. We describe the efficacy and adverse events associated with a modified epidural needle (ES) versus a conventional Tuohy needle for CSE. One-hundred parturients requesting labor analgesia (CSE) were randomized into 2 groups: 50-ES 18-gauge modified epidural needle with 27-gauge Pencan atraumatic spinal needle, 50-conventional 18-gauge Tuohy needle with 27-gauge Gertie Marx atraumatic spinal needle. Information on intrathecal or intravascular catheter placement, paresthesia on introduction of spinal needle, failure to obtain CSF through the spinal needle after placement of epidural needle, unintentional dural puncture, and epidural catheter function was obtained. No intrathecal catheter placement occurred in either group. Rates of intravascular catheter placement and unintentional dural puncture were similar between the groups. Significant differences were noted regarding spinal needle-induced paresthesia (14% ES versus 42% Tuohy needles, P = 0.009) and failure to obtain CSF on first attempt (8% ES versus 28% Tuohy needles, P < 0.02). Use of ES needles for CSE significantly reduces paresthesia associated with the insertion of the spinal needle and is associated with more frequent successful spinal needle placement on the first attempt. IMPLICATIONS: The use of modified epidural needles with a back hole for combined spinal-epidural technique significantly reduces paresthesia associated with the insertion of the spinal needle and is associated with more frequent successful spinal needle placement on the first attempt.     

Combined spinal-epidural for labor analgesia

Since the introduction of the combined spinal-epidural technique in the early 1980s it has gained increasing popularity for analgesia and anesthesia in labor and delivery. The benefit of the rapid onset of analgesia from the intrathecal injection, coupled with the flexibility of an epidural catheter that can provide a long duration of labor analgesia or conversion to an anesthetic when operative delivery is necessary, has made combined spinal-epidural the labor analgesic of choice in many obstetric anesthesia practices.     

Combined spinal-epidural labor analgesia

Combined spinal-epidural (CSE) labor analgesia is a new neuraxial labor analgesic technique. An intrathecal injection of an opioid alone, or in combination with a local anesthetic, initiates analgesia. An epidural catheter can then be used to maintain pain relief for the duration of labor. The CSE technique combines the advantages of spinal analgesia (low drug doses, rapid onset, immediate sacral block) and epidural analgesia (titratable, able to maintain analgesia indefinitely, ability to convert to epidural anesthesia). Side effects are acceptable with attention to patient selection and technique. The initiation of CSE analgesia with either fentanyl (25 μg) or sufentanil (5.0–7.5 μg) is appropriate for early labor, or in patients for whom an acute decrease in preload is not desirable. Although an equipotent dose of sufentanil has a longer duration of analgesia than fentanyl, both drugs provide excellent analgesia and prolonged duration is of minimal clinical significance when the intrathecal dose is followed by maintenance epidural analgesia. The addition of a local anesthetic to the opioid is required to provide satisfactory analgesia once fetal descent begins. The addition of local anesthetic (usually bupivacaine 1.25–2.5 mg) allows the dose of opioid to be decreased. Markedly lower opioid doses (fentanyl 5 μg or sufentanil 1.0–2.5 μg) can then provide effective analgesia with fewer systemic side effects. Several additives have been shown to prolong the duration of analgesia of opioids and opioids plus bupivacaine, but the short increase in duration of analgesia may not be worth the increased difficulty of combining multiple drugs.     

Dural Puncture with a 27-Gauge Whitacre Needle as Part of a Combined Spinal-Epidural Technique Does Not Improve Labor Epidural Catheter Function

Background: This prospective, double-blind, randomized study was designed to examine whether the combined spinal-epidural technique without subarachnoid drug administration improved epidural catheter function when compared with the traditional epidural technique.

Methods: After institutional review board approval and informed consent, 251 healthy laboring parturients were randomly assigned to either group DP (combined spinal-epidural technique with 27-gauge Whitacre needle dural puncture but without subarachnoid drug administration) or group NoDP (traditional epidural technique). Patient-controlled epidural analgesia was initiated with 0.11% bupivacaine and 2 [mu]g/ml fentanyl. Top-up doses in 5-ml increments of 0.25% bupivacaine were administered if needed. Previous power analysis revealed that a sample size of 108 patients/group was needed to show a clinically useful reduction of the catheter manipulation rate from 32% to 15%.

Results: In groups DP and NoDP, 107 and 123 evaluable patients, respectively, completed the study. Demographics and outcome variables measured, including epidural catheter manipulation and replacement rate, sacral sparing, unilateral block, number of top-up doses, average hourly epidural drug usage, highest sensory blockade level, and labor analgesia quality, were not different between groups. A subgroup of 18 patients without cerebral spinal fluid return during dural puncture had a higher catheter replacement rate than those of groups DP and NoDP, but it did not reach statistical significance.     

Injecting saline through the epidural needle decreases theiv epidural catheter placement rate during combined spinal-epidural labour analgesia

PURPOSE: To determine if injecting 10 mL saline before epidural catheter threading (pre-cannulation epidural fluid injection) can decrease the incidence of iv epidural catheter placement during combined spinal-epidural (CSE) labour analgesia. METHODS: One hundred healthy women requesting CSE labour analgesia with either fentanyl 20 microg or sufentanil 10 microg were prospectively randomized to receive either no epidural injection (dry group, n = 50) or epidural 10 mL saline injection (saline group, n = 50) before epidural catheter placement. A nylon multiport catheter was then threaded 3-5 cm into the epidural space and the needle was removed. We diagnosed iv catheter placement if blood was freely aspirated, if the mother became tachycardic after injection of epinephrine 15 microg, or if intracardiac air was heard (using ultrasound) after injection of air 1.5 mL. RESULTS: Intravenous epidural catheter placement occurred in one saline and ten dry group patients (P < 0.01). No complications of excessive cephalad intrathecal opioid spread (i.e., difficulty swallowing, hypoxemia, or respiratory arrest) occurred. CONCLUSIONS: Injecting 10 mL or saline through the epidural needle after intrathecal opioid injection and before threading the catheter significantly decreased accidental venous catheter placement without any apparent increase in complications from excessive cephalad intrathecal opioid spread.     

The combined spinal-epidural technique

Epidural and spinal blocks are well-accepted regional techniques, but they have several disadvantages. The CSE technique can reduce or eliminate the risks of these disadvantages. CSE block combines the rapidity, density, and reliability of the subarachnoid block with the flexibility of continuous epidural block to extend duration of analgesia. The CSE technique is used routinely at many institutions, particularly for major orthopedic surgery and in obstetrics. It has been used in tens of thousands of patients without any reports of major problems. Although at first sight the CSE technique appears to be more complicated than epidural or spinal block alone, intrathecal drug administration and siting of the epidural catheter are both enhanced by the combined, single-space, needle-through-needle method. Concerns about the epidural catheter entering the theca via the small puncture hole are now considered to be unfounded, but as with all epidural catheter techniques, vigilant monitoring of the patient during and after any injection is paramount. CSE is an effective way to reduce the total drug dosage required for anesthesia or analgesia. The intrathecal injection achieves rapid onset with minimal doses of local anesthetics and opioids, and the block can be prolonged with low-dose epidural maintenance administration. In addition, the sequential CSE method can be used to extend the dermatomal block with minimal additional drugs or even saline. Reduction in total drug dosage has made truly selective blockade possible. Many studies have confirmed that low-dose CSE with local anesthetic and opioid, or low-dose epidural block alone, will provide effective analgesia with minimal motor and proprioceptive block. Such neurologic selective blockade has made it possible for most patients to walk and bear down normally in labor or postoperatively. There remains concern about the risk of infection being increased when the CSE technique is used in place of epidural block alone. Despite a recent flurry of reports of meningitis with CSE procedures, there is no evidence the CSE block is more hazardous than epidural or subarachnoid block alone. Arguably, the single-space, needle-through-needle CSE technique will continue to improve with new needle designs and other advances to improve further the success rate and reduce complications, such as neurotrauma, PDPH, and infection. Over the past decade it has become clear that the CSE technique is a significant advance in regional blockade.     

Combined spinal-epidural analgesia in advanced labour

The combined spinal-epidural technique is a modification of epidural analgesia which combines the rapid onset of spinal analgesia with the flexibility of an epidural catheter. We sought to evaluate the effectiveness of an intrathecal opioid — low-dose local anaesthetic combination for parturients in advanced labour, a setting where satisfactory epidural analgesia is often difficult to achieve. The technique was evaluated in an open-label, non-randomized trial using parturients in advanced, active labour for the provision of pain relief during the late first stage and second stage of labour. Thirty-eight term parturients in active, advanced labour received a spinal injection of bu-pivacaine 2.5 mg and sufentanil, 10 μg, via a 25- or 27-gauge Whitacre needle placed into the subarachnoid space through a 17- or 18- gauge Weiss epidural needle which had been placed into the epidural space. This was followed by placement of an epidural catheter for supplemental analgesia if required. Onset of analgesia was noted by asking patients if their contractions were comfortable. Motor blockade was assessed using the Bromage criteria. Patients were asked if they experienced either pruritus or nausea on a four-point scale (none, mild, moderate, severe). The mean cervical dilatation at placement of the spinal medication was 6.1 ± 2.2 cm. Thirty-two patients had spontaneous vaginal delivery, two were delivered by outlet forceps, and four by Caesarean section. Onset of analgesia was rapid (< five minutes) in all cases. Twenty-three patients (60%) delivered vaginally with no additional anaesthetic. The remaining 15 had supplemental local anaesthetic given via the epidural catheter, a mean of 123 ± 33 min after the original spinal dose. Side effects were limited to pruritus in eight (21%) patients, and mild lower extremity motor weakness in one patient. One patient experienced transient hypotension. No patient developed postdural puncture headache. This technique allows for profound analgesia with a rapid onset and few bothersome side effects. In particular, the absence of motor blockade may facilitate maternal expulsive efforts or positioning during the second stage of labour.     

Ambulation with combined spinal-epidural labor analgesia: the technique

The combined spinal-epidural labor analgesia technique (CSEA) has attained wide spread popularity in obstetric anesthesia worldwide. The onset of analgesia is rapid and reliable, and maternal satisfaction is high. While there still remains some concern about dural puncture, the CSEA technique offers many advantages to the parturient. For ambulatory labor analgesia the CSEA technique offers the possibility of combining rapid onset of subarachnoid analgesia with the flexibility of continuous epidural analgesia. This approach with the application of low-dose local anesthetic and/or opioid can provide a very selective sensory block with minimal motor blockade, allowing parturients to ambulate. This article will attempt to assess the validity of some strongly held opinions of whether CSEA offers any advantages for ambulatory labor analgesia as well as highlight some selected technical aspects and controversies of the CSEA specifically applicable to ambulatory labor analgesia.     

201 combined spinal-epidurals for anaesthesia using a separate needle technique

BACKGROUND AND OBJECTIVE: Combined spinal-epidural (CSE) anaesthesia may be performed using separate needles or by passing the spinal needle through an epidural needle. The latter technique requires that subarachnoid block is performed before the epidural catheter is placed. This paper examines a series of 201 consecutive CSEs performed with a novel separate needle technique, designed to avoid potential and actual problems associated with the CSE technique. METHODS: The CSE technique involved placement of the spinal needle in the subarachnoid space, followed by replacement of the spinal needle stylet. The epidural catheter was then positioned separately before returning to the spinal needle and injecting the subarachnoid drug. RESULTS: The technique had a high technical success rate. Both needles were successfully placed in 200 (99.5%) cases. Spinal anaesthesia was successful in all cases. The epidural catheter was used in 179 cases and failure of the epidural occurred in 2 (1.1%) cases. Paraesthesia, inability to advance the epidural catheter or blood in the epidural catheter occurred in 31 (15.4%) and necessitated immediate replacement of the epidural catheter in 14 (7%) cases. Postoperatively, typical post-dural puncture headache was reported by one patient (0.5%) and mild backache by four (2%). There were no neurological complications. CONCLUSIONS: This method of CSE anaesthesia can be associated with high success and low complication rates.     

Combined spinal-epidural anesthesia for renal transplantation

INTRODUCTION: A patient undergoing renal transplantation presents unique problems to the anesthetist, as almost every body system is affected. The combined spinal-epidural technique has become popular in lower abdominal surgeries because it offers the advantages of both spinal and epidural techniques. We review our experience of combined spinal-epidural technique in patients undergoing renal transplantation with respect to demographics, intraoperative anesthesia, hemodynamics, postoperative analgesia, and untoward adverse events. MATERIALS AND METHOD: Fifty consecutive patients scheduled for elective renal transplantation over a period of 4 months who consented for combined spinal-epidural anesthesia were enrolled in the study. Combined spinal-epidural anaesthesia was performed using a double-space technique in the right lateral position. Intraoperative monitoring included electrocardiography, pulse oximetry, noninvasive blood pressure, central venous pressure, and urinary output after clamp release. Intravenous fluids, colloids, and blood products were infused so as to keep the central venous pressure between 12 and 15 mm Hg. Postoperative analgesia was provided with buprenorphine via an epidural catheter. We noted intraoperative and postoperative complications. RESULTS: Neuraxial blockade was satisfactory in all but four patients who required supplementation with general anesthesia for unduly prolonged surgery. There were no significant intraoperative hemodynamic changes. The total intravenous fluid used during surgery was 64.24 +/- 12.3 mL/kg. During the postoperative period, all patients had good postoperative pain relief with no incidence of epidural hematoma. CONCLUSION: Combined spinal-epidural anesthesia proved to be a useful regional anesthetic technique, combining the reliability of spinal block and versatility of epidural block for renal transplantation.     

Combined spinal-epidural analgesia in labor--comparison of sufentanil vs tramadol

BACKGROUND: Combined spinal-epidural (CSE) analgesia is becoming increasingly used to provide pain relief during labor. It combines both the rapid onset of the spinal analgesia and the flexibility of the epidural catheter. Intrathecal sufentanil provides rapid-onset and profound analgesia during the first stage of labor. The dose required to produce this effect can be associated with maternal respiratory depression, hypotension, nausea, or pruritus. The major concern of the anesthesiologist is to limit these side effects sources of discomfort to a parturient, by choosing the optimal dose of sufentanil or searching for an alternative. The purpose of this study is to compare tramadol and sufentanil used in CSE analgesia in terms of duration of analgesia and frequency of adverse maternal or fetal effects. METHODS: Forty parturients requesting labor analgesia were included in this prospective study. In a combined spinal- epidural technique, at 3 to 4 cm cervical dilation, patients were randomly assigned to receive either one of the following intrathecal solutions: 2.5 mg sufentanil (n = 20) and 2.5 mg bupivacaine, or 25 mg tramadol (n = 20) and 2.5 mg bupivacaine. Visual analog scores for pain, blood pressure, heart rate, sensory levels, incidence of nausea and pruritus, motor blockade, and maternal satisfaction, were recorded. RESULTS: Patients receiving 25 mg intrathecal tramadol with 2.5 mg bupivacaine had significantly longer-lasting analgesia (114 +/- 7 min). than those receiving 2.5 mg intrathecal sufentanil and 2.5 mg bupivacaine (54 +/- 11 min). No adverse maternal or fetal effects were noted in the group sufentanil. Five parturients of the tramadol group, presented vomiting 10 min after induction. There was no difference in the time from analgesia to delivery, incidence of operative or assisted delivery or cervical dilation. During labor, maternal satisfaction was good. CONCLUSIONS: 2.5 micrograms of intrathecal sufentanil combined with 2.5 mg bupivacaine provides rapid-onset and profound analgesia during the first stage of labor without adverse maternal or fetal effects. 25 mg intrathecal tramadol with 2.5 mg bupivacaine had longer-lasting analgesia. The major side effect was vomiting.     

Combined spinal-epidural analgesia for labor in a patient with Marfan's syndrome

We report the management of a patient with Marfan's syndrome for labor analgesia and vaginal delivery using a combined spinal-epidural technique. The rapid onset of analgesia for the first stage of labor provided by the intrathecal opioid, combined with the slow and controlled onset of sensory anesthesia and sympathetic block provided by the dilute epidural local anesthetic, may make this technique particularly useful for labor and delivery in patients with Marfan's syndrome.     

Sensorimotor anesthesia and hypotension after subarachnoid block: combined spinal-epidural versus single-shot spinal technique

The extent of the intrathecal compartment depends on the balance between cerebrospinal fluid and subatmospheric epidural pressure. Epidural insertion disrupts this relationship, and the full impact of loss-of-resistance on the qualities of subarachnoid block is unknown. In this study we sought to determine if subarachnoid block, induced by combined spinal-epidural (CSE) using loss-of-resistance to air could render higher sensory anesthesia than single-shot spinal (SSS) when an identical mass of intrathecal anesthetic was injected. Sixty patients, scheduled for minor gynecological procedures, were randomly allocated into three groups all receiving 10 mg of 0.5% hyperbaric bupivacaine. In the SSS group, intrathecal administration was through a 27-gauge Whitacre spinal needle inserted at the L3-4 level. For the CSE group, the epidural space was identified with an 18-gauge Tuohy needle using loss-of-resistance to 4 mL of air. After intrathecal administration, a 20-gauge catheter was left in the epidural space. No further drug or saline was administered through the catheter. The procedure was repeated in group CSE ((no-catheter)) except without insertion of a catheter. Sensorimotor anesthesia was assessed at regular 2.5-min intervals until T10 was reached. In all aspects, there was no difference between CSE and CSE ((no-catheter)). Peak sensory level in SSS was lower than CSE and CSE ((no-catheter)) (median T5 [max T3-min T6] versus (T3 [T1-4] and (T3 [T2-5]) (P < 0.01). During the first 10 min postblock, dermatomal thoracic block was the lowest in SSS (P < 0.05). Time for regression of sensory level to T10 was also shortest in SSS. Hypotension, ephedrine use and period of motor recovery were more pronounced in CSE and CSE ((no-catheter)). We conclude that subarachnoid block induced by CSE produces greater sensorimotor anesthesia and prolonged recovery compared with SSS. There is also a more frequent incidence of hypotension and vasoconstrictor use despite using identical doses and baricity of local anesthetic. IMPLICATIONS: This study confirms that induction of subarachnoid block by a combined-spinal epidural technique produces a greater sensorimotor anesthesia and results in prolonged recovery when compared with a single-shot spinal technique. There is a more frequent incidence of hypotension and vasoconstrictor administration despite identical doses of intrathecally administered local anesthetic.     

Combined spinal-epidural versus epidural labor analgesia

BACKGROUND: Despite the growing popularity of combined spinal-epidural analgesia in laboring women, the exact role of intrathecal opioids and the needle-through-needle technique remains to be determined. The authors hypothesized that anesthetic technique would have little effect on obstetric outcome or anesthetic complications. METHODS: Data were prospectively collected from 2,183 laboring women randomly assigned to have labor analgesia induced with either 10 microg intrathecal sufentanil with or without 2.0 mg bupivacaine (n = 1,071) or 10 microg epidural sufentanil and 12.5-25.0 mg bupivacaine (n = 1,112). Immediately after induction, a continuous epidural infusion of 0.083% bupivacaine plus 0.3 microg/ml sufentanil was begun in all patients and continued until delivery. Labor was managed by nurses, obstetricians, and obstetric residents who were unaware of the anesthetic technique used. RESULTS: Anesthetic technique lacked impact on our primary outcome: mode of delivery or labor duration. Infants whose mothers were allocated to the combined spinal-epidural group had a slightly higher umbilical artery carbon dioxide partial pressure (54.2 +/- 10.4 vs. 53.2 +/- 10.2 mmHg). However, only achieving at least 5 cm cervical dilation before induction of analgesia and having a cesarean delivery were independent risk factors for elevated umbilical artery carbon dioxide partial pressure. The frequencies of accidental dural puncture, failed epidural analgesia, headache, and epidural blood patch were low and similar in the two groups. CONCLUSIONS: Labor progress and outcome are similar among women receiving either combined spinal-epidural or epidural analgesia. The difference in neonatal outcome appears related to the presence of confounding variables. The combined spinal-epidural technique is not associated with an increased frequency of anesthetic complications. Either technique can safely provide effective labor analgesia.     

Combined spinal and epidural anesthesia for orthopaedic surgery in the elderly]

The pros and cons as to which anesthesia is more beneficial, either spinal or epidural, prompted us to perform combined spinal and epidural block in the elderly undergoing lower limb surgery. The selected epidural space was entered with a 17-gauge Tuohy needle and a longer 26-gauge spinal needle was passed through it and into the subarachnoid space. Following the injection of required dose of 2% preservative-free lidocaine (isobaric), spinal needle was withdrawn and an epidural catheter was inserted. We could use this combined technique on 17 patients older than 80 yr (mean age; 84.5 +/- 3.9 years) with satisfactory results and without any serious cardiovascular change, as with 17 middle-aged patients (57.5 +/- 5.2 years). This combination of techniques provides a rapid onset and reliability of spinal block with high quality analgesia by supplementation through the epidural catheter during and after surgery. In the orthopaedic procedures on the lower limbs, combined spinal and epidural block is more useful even for the elderly over the age of 80 yr than spinal or epidural anesthesia alone.