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.     

The median effective dose of intrathecal hyperbaric bupivacaine is larger in the single-shot spinal as compared with the combined spinal-epidural technique

The combined spinal-epidural technique (CSE) has been associated with prolonged motor recovery and more frequent arterial hypotension as compared with a single-shot spinal (SSS) technique. We determined the median effective dose (MED) of intrathecal hyperbaric bupivacaine for CSE and SSS by using the up-down sequential allocation technique. Sixty male patients were randomly allocated to receive intrathecal administration through an SSS or CSE technique. Needle insertion occurred at the L3-4 interspace in all patients. In SSS, 9.5 mg of hyperbaric bupivacaine was administered through a 27-gauge Whitacre spinal needle. In CSE, a 17-gauge Tuohy needle with 4 mL of air was used to locate the epidural space, through which a 27-gauge Whitacre spinal needle was introduced and 7.0 mg of hyperbaric bupivacaine was administered. The dosing adjustment was 0.5 mg. A "successful" outcome was arbitrarily defined as sensory anesthesia at or above the T6 dermatome lasting for 60 min. A "success" resulted in a 0.5-mg decrement, whereas a "failure" resulted in a 0.5-mg increment in the next patient. There were 13 successes in both groups. The MED of bupivacaine was 9.18 mg (95% confidence interval, 8.89-9.47 mg) for CSE as compared with 11.37 mg (95% confidence interval, 10.88-11.86 mg) for SSS (P < 0.001). CSE required 19.3% (95% confidence interval, 14.9%-23.6%) less local anesthetic to achieve the defined clinical target. We found significant discrepancies in the MED of hyperbaric bupivacaine between the two techniques. Under similar clinical conditions, a 20% decrement in the dose of bupivacaine may be warranted whenever CSE is intended in place of SSS.     

Combined spinal-epidural anesthesia using epidural volume extension leads to faster motor recovery after elective cesarean delivery: a prospective, randomized, double-blind study

Epidural volume extension (EVE) via a combined spinal-epidural (CSE) technique is the enhancement of a small-dose intrathecal block by epidural saline boluses. In this prospective, randomized, double-blind study, we compared the EVE technique with single-shot spinal anesthesia with respect to its sensory and motor block profile and hemodynamic stability. Sixty-two parturients (n = 31 in each group) undergoing elective cesarean deliveries were administered either spinal anesthesia with hyperbaric 0.5% bupivacaine 9 mg and fentanyl 10 microg or CSE comprising intrathecal hyperbaric 0.5% bupivacaine 5 mg with fentanyl 10 microg, followed by 0.9% saline 6.0 mL through the epidural catheter 5 min thereafter. In each group, the lowest systolic blood pressure (SBP), sensory block level to loss of pain from pinprick, and modified Bromage scores were recorded at 2.5-min intervals. The visual analog pain score (VAS), peak sensory block height, highest modified Bromage motor score, time for sensory regression to the tenth thoracic dermatome (T10), and motor block recovery were compared between groups. Both groups were comparable in demographic data, VAS scores, peak sensory block height, time for sensory regression to T10, and lowest SBP recorded. Patients in the EVE group demonstrated significantly faster motor recovery to modified Bromage 0 (73 +/- 33 min versus 136 +/- 32 min, P < 0.05). IMPLICATIONS: When compared with conventional, single-shot spinal anesthesia, epidural volume extension of a small-dose spinal block provides satisfactory anesthesia for cesarean delivery with only 55% of the bupivacaine dose required and is associated with faster motor recovery of the lower limbs.     

Single-shot spinal anaesthesia, combined spinal-epidural and epidural volume extension for elective caesarean section: a randomized comparison

BackgroundSingle-shot spinal and combined spinal-epidural block, with or without epidural volume extension, can be used for caesarean section. There is no trial comparing their block characteristics and adverse effects under identical conditions.Methods60 ASA I or II parturients with gestational age 37 weeks or more, scheduled for elective caesarean section under regional anaesthesia, were included in the trial. Women were randomized to three groups: group SSS: single-shot spinal; group CSE: combined spinal-epidural; group EVE: epidural volume extension of a combined spinal-epidural. Intrathecal injection was identical in the three groups (0.5% hyperbaric bupivacaine 9 mg with fentanyl 10 μg) and was injected via a 25-gauge pencil-point spinal needle, either as a single-shot spinal or through the spinal needle of the needle-through-needle CSE set. In group EVE, 5 mL of normal saline was injected through the epidural catheter. All blocks were performed with the women sitting. Haemodynamic parameters and block characteristics were assessed.ResultsThe onset of maximum sensory and motor block was significantly faster in the SSS group than in the other two. Extent and duration of sensory and motor block and the incidence of adverse effects were similar in the three groups (P > 0.05).ConclusionsIntrathecal block is similar in extent and duration whether given as a single-shot spinal or a combined spinal-epidural with or without epidural volume extension when performed for elective caesarean section using hyperbaric bupivacaine in the sitting position.     

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.     

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 low-dose spinal-epidural anesthesia versus single-shot spinal anesthesia for elective cesarean delivery

Combined spinal-epidural anesthesia balancing low-dose intrathecal bupivacaine/fentanyl and low-dose epidural bupivacaine may be more useful than single-shot spinal anesthesia for cesarean delivery in reducing incidences of adverse effects such as hypotension and nausea and in shortening motor recovery. Combined spinal-epidural anesthesia (n=50) or spinal anesthesia (n=50) was randomly performed in 100 parturients. Intrathecal bupivacaine 6 mg added by fentanyl 20 mug followed after 5 min by 10 mL of 0.25% epidural bupivacaine were used for combined spinal-epidural and intrathecal bupivacaine 9 mg with fentanyl 20 mug for spinal anesthesia. The initial sensory block level was higher in the spinal group (P<0.001), although the maximum levels were the same (T3). Complete surgical anesthesia was achieved and no patient complained of intraoperative pain in either group. Patients in the spinal group had denser motor block in the extremities and a higher incidence of hypotension (P<0.05) and nausea and vomiting (P<0.05). Motor recovery was faster in the combined spinal-epidural group (P<0.001). We concluded that combined spinal-epidural anesthesia using low-dose local anesthetic-opioid spinal anesthesia and routine epidural supplementation before surgery had some potential advantages over single-shot spinal anesthesia in the lower incidences of adverse effects and quicker recovery.     

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.     

Role of repeated epidural injections in preventing post-spinal hearing loss

Study ObjectiveTo determine if epidural volume extension and continued postoperative epidural injections prevent hearing loss associated with a 23-gauge (G) Quincke spinal needle.DesignProspective, double blinded trial.SettingOperating rooms.Patients30 adult patients scheduled for lower abdominal or perineal surgery during spinal anesthesia.InterventionsPatients were divided into two groups of 15 each. All patients received subarachnoid injection with a 23-G Quincke needle. While patients in Group S received a single-shot spinal, Group E patients underwent epidural catheter placement one intervertebral space above. The epidural catheter was bolused with 10 mL of normal saline followed by postoperative epidural boluses of local anesthetic for analgesia as needed.MeasurementsPatients’ auditory function was evaluated by pure tone audiometry (frequencies of 250-8,000 Hz) on the day before and two days after receiving the spinal anesthesia.Main ResultsUnilateral low-frequency hearing loss (500 Hz) was seen in Group S (P < 0.05). It was prevented by the repeated epidural injections as used in Group E.ConclusionFollowing spinal anesthesia, epidural volume extension with 10 mL of normal saline followed by epidural local anesthetic boluses titrated to adequate postoperative analgesia (6-8 mL each time) prevents post-spinal hearing loss.     

Decrease in the incidence of post-dural puncture headache: maintaining CSF volume

The incidence of epidural needle-induced post-dural puncture headache (PDPH) in parturients following dural puncture with a large bore (18-gauge) needle has been reported to range 76-85%. We describe seven cases in which the performance of epidural anesthesia in parturients was complicated by an unintentional dural puncture with an 18-gauge epidural needle. In all seven cases, the unintentional dural puncture was followed by (i) injection of the CSF in the glass syringe back into the subarachnoid space through the epidural needle, (ii) insertion of a epidural catheter into the subarachnoid space (now referred to as an intrathecal catheter), (iii) injection of a small amount of preservative free saline (3-5 ml) into the subarachnoid space through the intrathecal catheter, (iv) administration of bolus and then continuous intrathecal labor analgesia through the intrathecal catheter and then (v) leaving the intrathecal catheter in-situ for a total of 12-20 h. PDPH occurred in only one of these cases (14%).     

Prevention strategy for post dural puncture headache

We report the anesthetic management of a parturient after an unintentional dural puncture while performing epidural anaesthesia for caesarean section and the strategy to prevent postdural puncture headache (PDPH). We injected the cerebrospinal fluid (CSF) back into the subarachnoid space and then administered intrathecal 1.5 mL 0.5% hyperbaric bupivacaine and fentanyl 20 microg to maintain CSF volume via epidural needle. The epidural catheter was inserted following re-identification of the epidural space for possible epidural top-up requirement and postoperative pain relief. After adding 3 mL of 0.5% isobaric bupivacaine via epidural catheter, sensory block level reached at T4 bilaterally. No PDPH was observed.     

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.     

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.     

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.     

Patient-controlled epidural analgesia with fentanyl-bupivacaine: influence of prior dural puncture

BACKGROUND AND OBJECTIVES: Combined spinal epidural anesthesia (CSEA) involves the epidural administration of local anesthetic and opioid solutions adjacent to the prior dural puncture, potentially increasing their diffusion into the subarachnoid space. This study was designed to evaluate the influence of dural puncture on the adequacy and extent of analgesia, and drugs requirements of patient-controlled epidural analgesia (PCEA) in the postoperative period. METHODS: In this prospective double-blind study, 40 patients undergoing major abdominal surgery under general anesthesia followed with PCEA were randomly assigned to either group I (preoperative insertion of an epidural catheter) or group II (preoperative dural puncture with a 25-g Quincke needle + insertion of an epidural catheter). Postoperatively, a PCEA pump delivered an infusion of 0.1% bupivacaine + fentanyl (3 microg/mL) at 5 mL/h. Participants were allowed to self-administer 5-mL boluses of the same solution with a 15-minute lock-out interval. Hourly epidural solution requirements were recorded for 40 hours. Sensory and motor block, and pain scores were also analyzed. RESULTS: There was no difference between groups with regard to epidural solution requirements, pain scores, spread of sensory blockade, or intensity of motor block. CONCLUSION: Dural puncture with a 25-gauge Quincke needle, performed as part of CSEA, does not influence the drug requirements when a combination of 0.1% bupivacaine and fentanyl (3 microg/mL) is used for PCEA after major abdominal surgery.     

Comparison of three catheter sets for continuous spinal anesthesia in patients undergoing total hip or knee arthroplasty

BACKGROUND AND OBJECTIVES: Continuous spinal anesthesia (CSA) with microcatheters may be complicated because of technical problems. In elderly patients, some of the problems may be solved by using thicker catheters. A recent invention, involving a catheter-over-needle system, may prevent leakage of cerebrospinal fluid (CSF) and may also improve the prediction of the intrathecal position of the catheter tip. METHODS: This study included 90 patients undergoing primary hip or knee replacement, randomly allocated into 3 groups, with 30 patients in each group: Group EC, a 24-gauge epidural catheter through a 19-gauge Tuohy needle; group MC, a 28-gauge microcatheter through a 22-gauge spinal needle; group SC, a 22-gauge spinal catheter over a 27-gauge spinal needle through an epidurally placed 18-gauge Crawford needle. All subarachnoid catheterizations were performed with the patient in the lateral position and the initial spinal block dose was 2 mL of plain 0.5% bupivacaine. Increments of 0.5 mL were administered when required. The block performance characteristics were recorded, and the level of analgesia was studied in a blinded fashion. Catheter function during the postoperative infusion was assessed. Afterwards the needles and catheters were examined by microscopy. RESULTS: The frequency of the successful catheterization was higher in the EC and MC groups (90% in each) than in the SC group (63%) (P <.05). The mean duration of the successful catheterizations, as well as the median level of analgesia, were similar in the groups. The postoperative infusion had to be stopped in 3, 1, and 1 patients in groups EC, MC, and SC, respectively, because of a technical reason. No neurologic sequelae occurred in this study. Microscopy showed 4 distorted spinal needle tips (2 each with MC and SC) and minor material damage of the SC catheters when bone had been met during block performance. CONCLUSIONS: Placement of the SC catheters was unsuccessful to a high degree, and bone contact produced distortion of the tip of some of these catheters. Otherwise, the quality associated with catheterization time, anesthetic distribution, and catheter function was similar with the 3 catheters.     

Administration of local anesthetic through the epidural needle before catheter insertion improves the quality of anesthesia and reduces catheter-related complications

Epidural catheter placement offers flexibility in block management. However, during epidural catheter insertion, complications such as paresthesia and venous and subarachnoid cannulation may occur, and suboptimal catheter placement can affect the quality of anesthesia. We performed this prospective, randomized, double-blind study to assess the effect of a single-injection dose of local anesthetic (20 mL of 2% lidocaine) through the epidural needle as a priming solution into the epidural space before catheter insertion. We randomized 240 patients into 2 equal groups and measured the quality of anesthesia and the incidence of complications. In the needle group (n = 100), catheters were inserted after injection of a full dose of local anesthetic through the needle. In the catheter group (n = 98), the catheters were inserted immediately after identification of the epidural space. Local anesthetic was then injected via the catheter. We noted the occurrence of paresthesia, inability to advance the catheter, or IV or subarachnoid catheter placement. Sensory and motor block were assessed 20 min after the injection of local anesthetic. Surgery was initiated when adequate sensory loss was confirmed. In the catheter group, the incidence of paresthesia during catheter placement was 31.6% compared with 11% in the needle group (P = 0.00038). IV catheterization occurred in 8.2% versus 2% of patients in the catheter and needle groups, respectively (P = 0.048). More patients in the needle group had excellent surgical conditions than the catheter group (89.6% versus 72.9; P < 0.003). We conclude that giving a single-injection dose via the epidural needle before catheter placement improves the quality of epidural anesthesia and reduces catheter-related complications.     

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.     

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.