Combined spinal-epidural blockade

Published on 07/02/2015 by admin

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Last modified 07/02/2015

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Combined spinal-epidural blockade

Katherine W. Arendt, MD

Combined spinal-epidural (CSE) blockade was first described in 1937 but was not commonly used until the early 1980s. Combining the advantages of each of its component techniques, CSE blockade combines the rapid onset, reliability, and minimal drug toxicity associated with subarachnoid blocks with the flexibility of the dosing, duration, and analgesic-level control of an indwelling epidural catheter. CSE block is used primarily for obstetric analgesia and anesthesia, but its use has been described for a variety of applications, including general surgery, orthopedic and trauma surgery of the lower limb, urologic surgery, and gynecologic surgery.

Applied anatomy

The essence of a CSE block is single-shot administration of intrathecal anesthetic or analgesic agents along with placement of a catheter into the epidural space. The applied anatomy of a CSE block is the same as that for subarachnoid and epidural blockade (see Chapter 123, Epidural Anesthesia, Figure 123-1).

Indications

CSE blockade can be utilized in patients in whom a neuraxial technique is indicated and for whom it is necessary to combine the rapid onset of analgesia or anesthesia achieved with spinal anesthesia with the ability to provide prolonged analgesia, as is usually done with a continuous infusion of medication through an epidural catheter.

Contraindications

Contraindications for CSE block are the same as those for all neuraxial blocks (Table 124-1).

Table 124-1

Absolute and Relative Contraindications to Neuraxial Anesthesia/Analgesia

Absolute	Relative
Patient refusal Bacteremia/sepsis Increased intracranial pressure Infection at needle insertion site Shock or severe hypovolemia Coagulopathy or therapeutic anticoagulation*	Preexisting neurologic disease Severe psychiatric disease or dementia Aortic stenosis Left ventricular outflow tract obstruction Various congenital heart conditions (absolute contraindication if severe) Deformities or previous surgery of the spinal column

^*See Chapter 125.

Advantages

A systematic review comparing CSE and epidural labor analgesia found no evidence for differences in maternal satisfaction, mode of delivery, incidence of hypotension, or the ability to ambulate. However, the advantages of using a CSE technique (as opposed to an epidural technique alone) do exist and may include the following:

The onset of anesthesia or analgesia is faster.

The total dose of local anesthetic agent required to achieve analgesia/anesthesia is smaller than the dose necessary with an epidural-only technique, thus reducing the risk of local anesthetic toxicity. This may ultimately result in lower systemic and fetal (if used for labor and delivery) concentrations of local anesthetic agents.

For obstetric cases, intrathecal opioids can be administered as the sole agent, without the addition of local anesthetic drugs, providing analgesia for the first stage of labor with no motor block.

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