Combined spinal–epidural techniques

Abstract

SummaryThe 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 combined spinal-epidural technique (CSE) involves intentional subarachnoid blockade and epidural catheter placement during the same procedure. CSE allows a rapid onset of neuraxial blockade, which can subsequently be prolonged or modified. Ideally it combines the best features of spinal blockade (rapid onset, profound blockade, low drug dosage) and epidural blockade (titratable levels, ability to prolong indefinitely) and avoids their respective disadvantages (spinal: single-shot nature, unpredictable level of blockade; epidural: missed segments, incomplete motor block, poor sacral spread, local anaesthetic toxicity). However, it is a more complicated technique than either block alone and produces a multicompartment block. This introduces the potential for new complications and the modification of existing complications. CSE cannot be considered as simply a spinal block followed by an epidural block. A variety of techniques, equipment and regimens have been described. New complications and reasons for technical failure are encountered. Epidural injection may modify the spinal block and epidural drugs may not behave as they would without prior dural puncture. Review aims and methodThis review examines the current literature on technical aspects of the CSE technique and factors that distinguish it from either spinal or epidural blockade. The review does not consider different drug regimens or address the role of the technique as analgesia during labour. Owing to the limited number of randomised controlled trials and other high-quality research, the review is descriptive. Articles were found by Medline search through the years 1975-1999 using the search words 'spinal' or 'subarachnoid' and 'epidural' or 'extradural'. Reference lists in these publications were searched. The major anaesthetic journals were hand searched. This search identified 5...

Bupivacaïne intrathécale pure vs hyperbare pour l’analgésie du travail obstétrical: efficacité et effets secondaires

“…1,2 In active labour, the ideal analgesic mixture should deliver rapid onset of satisfactory analgesia while minimizing side effects. The initial characteristics of the block are mainly determined by the doses of medications (local anesthetic and opioid) and the baricity of the intrathecal solution.…”

Use of combined spinal‐epidural by obstetric anaesthetists

“…The pre-operative assessment should include direct questioning regarding symptoms of upper airway obstruction, hypernasal voice [1] and language difficulties in children to warn of velopharyngeal insufficiency or previous surgery. 2.…”

“…These notes will indicate whether the patient has had a simple cleft lip and palate repair or whether more complex surgery such as pharyngoplasty has been required. Pharyngoplasty is required in approximately 25% of cleft repairs, the incidence being related to the nature of original anatomical defect [1]. 3.…”

“…Teaching airway skills should be central to anaesthesia training, as problems with respiratory and airway management may lead to significant morbidity and mortality [1]. We previously reported that a training module for difficult airway management is often not provided in Japan and the UK [2], and that both the level of tutors' expertise with the use of each airway device (or procedure) and the format of the syllabus for trainees varies considerably between the two countries.…”

Comparison of the maternal and neonatal effects of combined spinal-epidural block and spinal block for cesarean section

“…Bu iki tekniğin avantajlarına sahip olmak ve dezavantajlarını azaltmak için önerilen kombine spinal-epidural (KSE) anestezi günümüzde yaygın olarak tercih edilir hale gelmiştir. [2] Bu prospektif, randomize çalışmada elektif sezaryen operasyonlarında spinal blok ile son yıllarda popü-laritesi giderek artan KSE bloğun anne ve yenidoğan üzerine etkilerinin incelenmesi amaçlanmıştır.…”