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 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.     

Combined subarachnoid-epidural technique for obstetric analgesia

Combined spinal-epidural blockade for labor pain has enjoyed increasing popularity in obstetric anesthesia. The usual procedure is to use a single space and a single needle for dural puncture, inserting a spinal needle through an epidural needle followed by insertion of a catheter. A small dose of one or several substances (usually a lipophilic opioid and a local anesthetic) is first injected in the intrathecal space to provide rapid, effective analgesia with minimal muscle blockade. The epidural catheter is used if labor lasts longer than the spinal block, if the spinal block is insufficient, or in case of cesarean section. Combined spinal-epidural blockade is a safe, valid alternative to conventional epidural analgesia and has become the main technique for providing obstetric analgesia in many hospitals. The most widely-recognized advantage of the technique is high maternal satisfaction with rapid and effective analgesia. Mobility of the lower extremities is preserved and the mother is often able to walk. Because opioids are injected into the intrathecal space and because the technique is more invasive than standard epidural analgesia, the potential risk to mother and fetus increases.     

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.     

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.     

Combined spinal epidural anesthesia

Combined spinal epidural (CSE) anesthesia is a technique that has been accepted readily for care of the obstetrical patient. In a previous report the author discussed the attributes of this technique that make it an increasingly popular choice for care of the surgical patient. CSE has special advantages for the patient undergoing ambulatory surgery. Dose response studies have been useful in determining a reliable short-acting alternative to epidural anesthesia for the ambulatory surgery patient. In fact, CSE with a low dose of lidocaine is a more reliable alternative to chloroprocaine anesthesia, with a very similar onset and offset profile. The preferred technique for CSE anesthesia is presented below with attention to the relevant functional anatomy that must be appreciated to have the technique work on a daily basis with minimal side effects and complications. The practicality of CSE has been questioned and the “failure rate” has been poorly defined in this regional technique that is still in its infancy. The basis of the failure rate of the needle-through-needle technique is discussed as well as practical alternatives that make a 100% success rate obtainable. Finally, the exact technique for needle-through-needle is presented in detail. The security of an epidural catheter allows for minimal dosing of local anesthetic and therefore more precise predictability of day surgery subarachnoid anesthesia. Copyright © 2000 by W.B. Saunders Company     

Combined spinal-epidural anesthesia for cesarean section; needle-through-needle approach

Purpose The Portex “Spinal/Epidural Set” is designed for combined spinal-epidural (CSE) anesthesia by the needle-through-needle approach. We evaluated the technical and clinical usefulness of CSE with this needle set, and also isobaric tetracaine, for cesarean section. Methods Thirty patients for cesarean section were included. In the left decubitus position, a 16-gauge epidural needle was introduced by the loss-of-resistance method into the lumbar intervertebral space. A 26-gauge spinal needle was threaded through the epidural needle into the subarachnoid space. Tetracaine dissolved in saline was injected. A 17-gauge catheter was advanced into the epidural space. The analgesic level was checked by the pin-prick method. Results The insertion in the first attempt was successful in 21 cases (70%) of the patients, and difficulty in insertion was not experienced. Inadvertent dural puncture occurred in one case, but no accidental subarachnoid catheterization was observed. Spinal anesthesia with tetracaine (11.1±0.5 mg) reached the level of Th₆ on average, with a relatively wide range. Five cases (13%) were supplemented by epidural anesthesia. No postspinal headache was noted. Conclusion CSE technique by the needle-through-needle approach is easy to handle, and provides a speedy, reliable, and flexible analgesia as well as postoperative pain relief for patients undergoing cesarean section.     

Combined spinal epidural causes higher level of block than equivalent single-shot spinal anesthesia in elective cesarean patients

Combined spinal epidural (CSE) is an established technique for lower segment cesarean delivery. In this study we tested the hypothesis that the spinal block from a CSE technique results in a more extensive spread of local anesthetic in the subarachnoid space than the single-shot spinal (SSS) technique. We recruited 30 ASA physical status I parturients admitted for elective lower segment cesarean delivery into our randomized, controlled, double-blind study. All patients intrathecally received 2 mL of 0.5% hyperbaric bupivacaine. The patients were randomized into one of the two groups using sealed opaque envelopes. Group S (n = 15) received a SSS technique. Group CS (n = 15) received a CSE technique using loss of resistance to 2 mL of air, but the epidural catheter was not inserted after the intrathecal drug administration. The maximal sensory block achieved in group CS was statistically higher than that in Group S (median C6 interquartile range, C5 to C8 versus median T3, T2 to T4, P < 0.001). Time taken to reach maximal sensory block was significantly longer in group CS. There were no differences in the time taken for the block to recede to T10, hemodynamic profile, or side effects. In conclusion, the CSE technique without placing an epidural catheter or administering epidural medication resulted in a significantly higher level of sensory block when compared with the SSS technique when the same dose of local anesthetic was given intrathecally.     

Comparison of technical and block characteristics of different combined spinal and epidural anesthesia techniques

BACKGROUND AND OBJECTIVES: The combined spinal and epidural (CSE) technique can reduce or eliminate some of the disadvantages of spinal and epidural anesthesia, while still preserving their advantages. CSE anesthesia is now commonly performed with a single-segment needle-through-needle technique; however, this technique involves some controversies about needle handling and the risk of catheter migration. To avoid some of these potential problems, special CSE sets have been produced. In the present study, 2 of these sets were compared with the traditional double-segment technique. METHODS: Ninety patients undergoing orthopedic surgery of the lower extremity were randomly allocated into 3 groups of equal size: Group 1, CSE set with an interlocking device between the spinal and epidural needle; group 2, CSE set with a "backeye" at the epidural needle curve for the passage of the spinal needle; group 3, double-segment technique. All epidural needles were 18-gauge, and spinal needles were 27-gauge with a pencil-point tip. In groups 1 and 2, the puncture was performed at the L3-4 interspace, and in group 3 the epidural catheter was first inserted at the L2-3 interspace followed by spinal puncture one interspace lower. Hyperbaric 0.5% bupivacaine, 2 mL, was used for the spinal block, and 4 mL of 2% lidocaine with epinephrine through the epidural catheter was used as a test dose. The block performance characteristics were recorded, and the level of analgesia was studied in a blinded fashion. Postoperatively, a bolus of epidural morphine 2 to 4 mg was used for the control of postoperative pain. All patients were interviewed on the 1st and the 7th postoperative days. Afterwards, the needles and catheters were examined by microscopy. RESULTS: The frequency of the successful CSE block was higher in groups 3 (100%) and 2 (90%) than in group 1 (63%) (P <.05). The mean duration of successful block performance, as well as the median level of analgesia, were similar in all the groups. One case of epidural catheter migration intrathecally was observed (group 1). Postoperative nausea and vomiting occurred in 23% of patients, and the incidence of postdural puncture headache was 2.2%. The incidence of backache at the puncture site was similar in the groups. Microscopy showed 6 distorted spinal needle tips (all in group 1), but no material damage to the epidural catheters. CONCLUSIONS: The use of the CSE sets does not seem to save time compared with the double-segment technique. Technical problems, unsuccessful CSE block, and damaged spinal needle tip were noted relatively often with the interlocking CSE set. Anesthetic characteristics in the successful blocks were similar with the different techniques.     

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.     

Comparison of combined spinal-epidural and low dose epidural for labour analgesia

PURPOSE: To compare the combined spinal-epidural (CSE) technique with the epidural technique with regard to time to initiate and manage, motor block, onset of analgesia and satisfaction during labour. METHODS: Upon requesting analgesia, 50 healthy term parturients were randomized in a prospective, double-blind fashion to receive either CSE analgesia or lumbar epidural analgesia in the labour floor of a university hospital at an academic medical centre. The epidural group (n = 24) received bupivacaine 0.0625%-fentanyl 0.0002% with 0.05 ml in 10 ml local anesthetic sodium bicarbonate 8.4% and epinephrine 1:200,000. The CSE group (n = 26) received intrathecal 25 microg fentanyl and 2.5 mg bupivacaine. Additional analgesia was provided upon maternal request. RESULTS: There were no differences (P>0.05) in time to perform either technique, motor blockade, or parturient satisfaction or in the number of times that the anesthesiologist was called to perform any intervention. Although the first sign of analgesia was not different between the two groups, the onset of complete analgesia was more rapid with the CSE technique (Visual Analogue Pain Score (VAPS) at five minutes < three: 26/26 vs. 17/24, P+/-0.001). CONCLUSION: Although epidural analgesia with a low concentration of local anesthetic and opioid mixture takes longer to produce complete analgesia, it is a satisfactory alternative to CSE.     

Combined spinal epidural vs epidural labour analgesia: does initial intrathecal analgesia reduce the subsequent minimum local analgesic concentration of epidural bupivacaine?

Labour analgesia initiated using a combined spinal-epidural (CSE) technique may reduce subsequent epidural bupivacaine requirements compared with an epidural-only technique. We compared the minimum local analgesic concentrations (MLAC) of epidural bupivacaine following initial intrathecal or epidural injection. In a prospective, double-blind study, 115 women requesting epidural analgesia were randomly assigned to receive either an epidural with bupivacaine 20 mg and fentanyl 40 μg or a CSE with intrathecal bupivacaine 2.5 mg and fentanyl 5 μg. Analgesia was assessed using a visual analogue pain score. When further analgesia was requested, bupivacaine 20 ml was given, and the concentration was determined using the technique of up-down sequential allocation. The MLAC of bupivacaine in the epidural group was 0.032% wt/vol (95% CI 0.020-0.044) compared with 0.047% wt/vol (95% CI 0.042-0.052) in the CSE group. Bupivacaine requirements for the second injection were increased following intrathecal analgesia by a factor of 1.45 (p = 0.026) compared with epidural analgesia.     

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     

Are combined spinal-epidural catheters reliable?

The combined spinal-epidural (CSE) technique can rapidly relieve labor pain. However, the location of the epidural catheter is initially uncertain. In an emergency, this untested catheter may fail to provide adequate anesthesia. This study compared the efficacy of catheters placed as a part of an epidural or needle-though-needle CSE technique in laboring women. Patients requesting pain relief received either epidural (n=601) or CSE (n=1061) analgesia. All patients had a 20 gauge, closed tip multi-holed polyamide catheter. (B. Braun Medical, Inc.) inserted 2-8 cm into the epidural space. Catheters were tested to rule out intrathecal and intravascular location. Then, epidural patients received 10-20 ml local anesthetic +/- opioid in divided doses. CSE patients received and infusion of 0.083% bupivacaine with opioid at 10-15 ml/h. Of the 1495 catheters that were adequately tested, those inserted as part of a CSE technique were more likely to produce bilateral sensory change and adequate analgesia than were those inserted without prior spinal analgesia (98.6% vs 98.2%, P<0.02). Stand-alone epidural catheters were more likely to produce neither sensory change nor analgesia than those inserted as part of CSE technique (1.3% vs 0.2%, P<0.02). The only catheters that failed completely and were not intravascular were stand-alone epidural catheters. In this clinical setting, catheters inserted as part of a CSE technique had a high probability of being in the epidural space and functioning appropriately.     

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.     

Combined spinal epidural (CSE) analgesia: technique, management, and outcome of 300 mothers

Epidural analgesia in labour is commonly associated with some degree of lower limb weakness often severe enough to be described as paralysis by the mother. We aimed to produce rapid reliable analgesia with no motor block throughout labour. We report a pilot survey of 300 consecutive women requesting regional analgesia in labour who received a combined spinal epidural blockade (CSE). The initial dose was given into the subarachnoid space and analgesia maintained via an epidural catheter. A subarachnoid injection of 2.5 mg bupivacaine and 25 mug fentanyl was successfully given in 268 women (89.3%). Completely pain-free contractions within 3 min of this injection occurred in 195 women (65%) and in all 300 within 20 min and there was no associated motor block in 291 (97%). 141 women chose to stand, walk or sit in a rocking chair at some time during labour. Only 38 women (12.6%) were immobile during the first stage of labour. Analgesia was maintained via the epidural catheter with bolus doses of 10-15 ml of 0.1% bupivacaine and 0.0002% fentanyl. The mean bupivacaine requirement was 9.5 mg/h throughout the entire duration of analgesia. The incidence of post lumbar puncture headache was 2.3%. Transient hypotension occurred in 24 women (8%) and was treated with 6 mg intravenous boluses of ephedrine. Complete satisfaction with analgesia and mobility was reported 12-24 h post partum by 95% of mothers. The use of this analgesic technique caused no alteration in obstetric management or post partum care of the women.     

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.     

Combined spinal epidural block versus spinal and epidural block for orthopaedic surgery

In a controlled study a single segment combined spinal epidural (CSE) block was compared with spinal or epidural block for major orthopaedic surgery. Seventy-five patients, age 52–86 yr, were randomly assigned to receive one of the three blocks. Bupivacaine 0.5% was used for surgical analgesia. The postoperative pain relief after 4.0 mg epidural morphine was compared with the analgesic effect of 0.2 or 0.4 mg morphine administered intrathecally. With the spinal technique good or excellent surgical analgesia and muscle relaxation were achieved rapidly (11.8 ± 1.1 min). The time taken to provide an equally effective and reliable block with the CSE technique was no longer (14.9 ± 2.2 min). For epidural block with the catheter technique more time was required (35.9 ± 3.9 min) to provide acceptable surgical conditions (P < 0.05). Perioperative sedatives and concomitant analgesics were required more frequently and in larger doses by the patients undergoing surgery with epidural block (P < 0.05) than with CSE or spinal block. Our study demonstrated that the analgesia after surgery provided by 0.2 and 0.4 mg morphine administered intrathecally was comparable to that provided by 4.0 mg of epidural morphine. It is concluded that the analgesia and surgical conditions provided by the spinal and CSE blocks were similar and were superior to those provided by an epidural block.     

Effects of epidural injection on spinal block during combined spinal and epidural anesthesia for cesarean delivery

BACKGROUND AND OBJECTIVES: Epidural injection has been known to enhance spinal anesthesia in combined spinal and epidural (CSE) anesthesia. Saline and local anesthetics have been reported to have a volume effect, elevating sensory level when supplementing a volume into the epidural space. We evaluated the effects of epidural injection when using the CSE technique for cesarean delivery. METHODS: Sixty-six parturients were allocated randomly into group C (control, n = 21), S (saline, n = 21), or B (bupivacaine, n = 24): epidural injections of 10 mL saline and 0.25% bupivacaine were given in groups S and B, respectively, 10 minutes after they received 8 mg of 0.5% hyperbaric bupivacaine intrathecally, and no injection was given in group C. The sensory level at 10 minutes, the maximal level and the time to reach it, and degree of motor block and muscle relaxation were compared. We also investigated intraoperative side effects and postoperative findings in the postanesthesia care unit. RESULTS: Epidural injection raised the sensory level significantly in groups S and B, but the maximal height of sensory block and degree of muscle relaxation did not differ among the groups. Fewer patients complained of intraoperative pain in group B than in the other groups (P <.001). CONCLUSIONS: We could not achieve satisfactory surgical analgesia with 8 mg of hyperbaric bupivacaine injected into the subarachnoid space using the needle-through-needle technique in cesarean deliveries. An epidural saline injection elevated the sensory level, which did not improve the spinal block, whereas an epidural injection of 10 mL of 0.25% bupivacaine enhanced the spinal block and sustained the block postoperatively.     

New developments in epidural anesthesia and analgesia

Several recent advances in epidural anesthesia and analgesia have been reviewed. Perhaps the most exciting area of anticipated future developments relates to the continued development of novel analgesic agents and new epidural delivery systems. There appears to be some movement toward an increased use of intrathecal or peripheral neural blockade techniques for some clinical situations where epidural anesthesia and analgesia have been previously used; however, the ability to provide anesthesia and analgesia to relatively large areas of the body with a single injection or continuous catheter technique without the associated risks of dural puncture and intrathecal catheter placement will continue to assure epidural anesthesia and analgesia techniques a prominent role in anesthesia and pain management.