Combined Spinal Combined Spinal Epidural Epidural

AnesthesiaAnesthesiaByBy

Capt Bilal BaigCapt Bilal BaigGraded AnesthetistGraded Anesthetist

Supervised bySupervised byCol Manzoor Ahmed FaridiCol Manzoor Ahmed Faridi

Classified AnesthetistClassified Anesthetist

CASE REPORTCASE REPORT

PATIENT XYZPATIENT XYZ AGE 25 YRSAGE 25 YRS ADDRESS PESHAWARADDRESS PESHAWAR DOA 23.05.07DOA 23.05.07

Presenting complaintsPresenting complaints

Gestational Amenorrhoea 09 Gestational Amenorrhoea 09 monthsmonths

Past historyPast history

Previous 02 C-SectionsPrevious 02 C-Sections h/o 01 laparotomy for ectopic h/o 01 laparotomy for ectopic

pregnancypregnancy

Drug history Drug history Family historyFamily history Socioecnomic history not Socioecnomic history not

contributorycontributory

Obstetrical historyObstetrical history

GG44PP33TT22AA11LL22

02 male02 male Married 06 yearsMarried 06 years Normal menstrual cycleNormal menstrual cycle

Genral Physical Genral Physical ExaminationExamination

Conscious ,well orientatedConscious ,well orientated Vital signs Vital signs

Pulse 72/minPulse 72/min BP 110/80mmhgBP 110/80mmhg Temp AfebrileTemp Afebrile

Systemic ExaminationSystemic Examination

CVSCVS CNS not contributoryCNS not contributory RespResp

Abdomen Abdomen FH 36wksFH 36wks FHS ++FHS ++ Cephalic PresentationCephalic Presentation

InvestigationsInvestigations

Blood CP Hb 9.7g/dlBlood CP Hb 9.7g/dl

Platelets 200x 10Platelets 200x 1099/l/l

TLC 6.4 x 109/lTLC 6.4 x 109/l BSR 4.7mmol/lBSR 4.7mmol/l Urine RE NADUrine RE NAD HBsAg & Anti HCV non reactiveHBsAg & Anti HCV non reactive USG abd normal 36 wks USG abd normal 36 wks

pregnancypregnancy

Planned for Elective C-Section due toPlanned for Elective C-Section due to

Previous 02 C-SectionsPrevious 02 C-Sections

Pre-Anesthesia Pre-Anesthesia AssesmentAssesment

h/o previous 03 GAh/o previous 03 GA Severe PONV associated with last GASevere PONV associated with last GA No h/o any systemic illnessNo h/o any systemic illness No h/o any bleeding disorderNo h/o any bleeding disorder No known drug allergyNo known drug allergy Exam of backExam of back

no deformityno deformity

no rash or scaringno rash or scaring

Pre-Anesthesia Pre-Anesthesia Assesment(contd)Assesment(contd)

No neurological deficitNo neurological deficit No h/o GERDNo h/o GERD

ASA 1ASA 1 MP 11MP 11

Anesthetic management Anesthetic management

Planned for c-Planned for c-section under section under regional regional anesthesia with anesthesia with combined spinal combined spinal epidural techniqueepidural technique

Patient counseled Patient counseled and consentedand consented

Fully explained the Fully explained the whole procedurewhole procedure

Anesthetic managementAnesthetic management

MonitoringMonitoring

BPBP

PulsePulse

SpO2SpO2

ECGECG

Anesthetic managementAnesthetic management

Preloaded with Preloaded with ringer lactate ringer lactate 1000ml/IV1000ml/IV

Left uterine Left uterine displacementdisplacement

Anesthetic managementAnesthetic management

Anesthetic managementAnesthetic management

Sitting positionSitting position Cleaned and Cleaned and

drapeddraped

Anesthetic managementAnesthetic management

Local infiltrationLocal infiltration Epidural space Epidural space

identified by a loss identified by a loss of resistance of resistance method with airmethod with air

Anesthetic managementAnesthetic management

Sub arachnoid's Sub arachnoid's space punctured space punctured with a long spinal with a long spinal needle and free needle and free flow of CSF flow of CSF confirmedconfirmed

Anesthetic managementAnesthetic management

3ml 0.50% bupivacaine isobaric 3ml 0.50% bupivacaine isobaric solution givensolution given

Anesthetic managementAnesthetic management

Epidural cathetar Epidural cathetar threadedthreaded

Secured with Secured with sticking plastersticking plaster

Anesthetic managementAnesthetic management

Level of the block Level of the block confirmed confirmed

Operation startedOperation started Vital signs Vital signs

monitored monitored Baby deliveredBaby delivered

Anesthetic managementAnesthetic management

Good neonatal Good neonatal outcomeoutcome

Suction and Suction and oxygenationoxygenation

Patient Patient comfortablecomfortable

No narcotics or No narcotics or sedationsedation

No antiemetic No antiemetic givengiven

5ml 5ml 0.125%bupivacain0.125%bupivacaine before shiftinge before shifting

No post op IV/IM No post op IV/IM analgesiaanalgesia

0.125%bupivacain0.125%bupivacaine in 5ml e in 5ml increments SOSincrements SOS

Remained very Remained very comfortablecomfortable

No PDPHNo PDPH Discharged on 2Discharged on 2ndnd

post Op daypost Op day

DISCUSSIONDISCUSSION

Background Background

The first epidural analgesia was done by Corning in The first epidural analgesia was done by Corning in 18851885

Bier , a surgeon was the first to inject cocaine into Bier , a surgeon was the first to inject cocaine into the spinal space. It was between August 16 and 27, the spinal space. It was between August 16 and 27, 1898. 1898.

these two compartments were first combined by these two compartments were first combined by Soresi in 1937. Soresi in 1937.

It took another 42 years until Curelaru in 1979 used It took another 42 years until Curelaru in 1979 used this combined spinal-epidural anesthesia again this combined spinal-epidural anesthesia again

Coates from England and Mumtaz, Daz and Kuz from Coates from England and Mumtaz, Daz and Kuz from Sweden, in 1982, first described the insertion of a Sweden, in 1982, first described the insertion of a long spinal needle through the epidural needle for long spinal needle through the epidural needle for performing the combined spinal-epidural anesthesia. performing the combined spinal-epidural anesthesia.

Anatomy of CSEAnatomy of CSE

AnatomyAnatomy

Spinal cordSpinal cord Begins at foramen magnum Begins at foramen magnum

Extends to sacral hiatusExtends to sacral hiatus

Three coveringsThree coverings

Pia , dura, arachnoidPia , dura, arachnoid

AnatomyAnatomy

Subarachnoid spaceSubarachnoid space

Between pia and arachnoidBetween pia and arachnoid

Cerebral ventricles to S2Cerebral ventricles to S2

Contain CSF spinal cord and its nerves &blood Contain CSF spinal cord and its nerves &blood vesselsvessels

CSF total 100ml-150ml below foraman magnum CSF total 100ml-150ml below foraman magnum 25-40ml25-40ml

Spinal cord extends to L3 at birth L1-2 by age 2Spinal cord extends to L3 at birth L1-2 by age 2

Tuffiers line corresponds to L4 Tuffiers line corresponds to L4

1-2 spaces above a safe margin1-2 spaces above a safe margin

AnatomyAnatomy Epidural spaceEpidural space Potential spacePotential space Triangular in shapeTriangular in shape Apex posteriorlyApex posteriorly Superiorly foramen magnumSuperiorly foramen magnum Inferiorly sacrococcygeal ligamentInferiorly sacrococcygeal ligament Anteriorly posterior longitudinal ligamentAnteriorly posterior longitudinal ligament Posteriorly ligamentum flavumPosteriorly ligamentum flavum Laterally dura lamina and pediclesLaterally dura lamina and pedicles Skin subcutaneous tissue supraspinous Skin subcutaneous tissue supraspinous

interspinous ligamentum flavum to reach epidural interspinous ligamentum flavum to reach epidural spacespace

AnatomyAnatomy

Subdural spaceSubdural spacePotential spacePotential space

Between dura and arachnoid materBetween dura and arachnoid mater

Inadvertent injection can cause failureInadvertent injection can cause failure

AnatomyAnatomy

Bony landmarksBony landmarks Made of vertebrae(7 cervical,12 Made of vertebrae(7 cervical,12

thoracic,5 lumbar,4coccygeal)thoracic,5 lumbar,4coccygeal)

Vertebral bodies ,2 pedicles, 2 laminaeVertebral bodies ,2 pedicles, 2 laminae

Bodies border anteriorly ,pedicles Bodies border anteriorly ,pedicles laterally and laminae posteriorlylaterally and laminae posteriorly

Spinous process horizontal in lumbar Spinous process horizontal in lumbar more caudal in thoracicmore caudal in thoracic

AnatomyAnatomy

Vertebral ligamentsVertebral ligaments3 encountered while neuraxial blockade3 encountered while neuraxial blockade SupraspinousSupraspinous InterspinousInterspinous Ligamentum flavumLigamentum flavum

80% elastin,characteristic feel ,significant 80% elastin,characteristic feel ,significant resistanceresistance

Physiology of Regional Physiology of Regional AnesthesiaAnesthesia

Inhibition of sodium channelsInhibition of sodium channels Absorption into systemic circulation terminate Absorption into systemic circulation terminate

actionaction Sequence of neural blockade on spinal anesthesiaSequence of neural blockade on spinal anesthesia

Sympathatic block wit vasodilatationSympathatic block wit vasodilatation Loss of pain and tempLoss of pain and temp Loss of proprioceptionLoss of proprioception Loss of pressureLoss of pressure Motor blockadeMotor blockade

Sympathetic blockade 2 segments higher than Sympathetic blockade 2 segments higher than sensorysensory

Motor blockade 2 segments lower than sensoryMotor blockade 2 segments lower than sensory Not very apparent during epidural anesthesia Not very apparent during epidural anesthesia

and patient can even ambulateand patient can even ambulate

Organ system effects of Organ system effects of regional anesthesiaregional anesthesia

Cardiovascular Sympathetic block VasodilatationSympathetic block Vasodilatation

Systemic vascular resistanceSystemic vascular resistance

hypotension & tachycardiahypotension & tachycardia If high enough to block cardiac If high enough to block cardiac

accelerator fibers at T1-T5 no tachycardia accelerator fibers at T1-T5 no tachycardia to decrease SVR and collapse to decrease SVR and collapse

Organ system effects of Organ system effects of regional anesthesiaregional anesthesia

Respiratory systemRespiratory system Lumbar spinal or epidural should no affectLumbar spinal or epidural should no affect Even at thoracic levels tidal volume not Even at thoracic levels tidal volume not

diminisheddiminished Small decrease in vital capacity due to loss Small decrease in vital capacity due to loss

of abdominal and intercostal musclesof abdominal and intercostal muscles Patients with severe lung disease on Patients with severe lung disease on

accessory muscles high thoracic spinal can accessory muscles high thoracic spinal can cause severe impairment necessitating cause severe impairment necessitating intubationintubation

Phrenic nerve (C3/4/5) provide ample Phrenic nerve (C3/4/5) provide ample oxygenation &ventilationoxygenation &ventilation

Organ system effects of Organ system effects of regional anesthesiaregional anesthesia

GI systemGI system Neuroaxial block causes Neuroaxial block causes

sympathectomysympathectomy Sympathatic outflow originates at T5-L1Sympathatic outflow originates at T5-L1 Unoppesed parasympathetic toneUnoppesed parasympathetic tone Increased peristalisisIncreased peristalisis

Organ system effects of Organ system effects of regional anesthesiaregional anesthesia

Urinary systemUrinary system Loss of autonomic bladder control Loss of autonomic bladder control

&urinary retention&urinary retention Bladder should be emptied with a Bladder should be emptied with a

cathetercatheter

Organ system effects of Organ system effects of regional anesthesiaregional anesthesia

Endocrine systemEndocrine system Partially block the release of Partially block the release of

catecholamines ,cortisol & ADHcatecholamines ,cortisol & ADH

Advantages of regional Advantages of regional anesthesia over general anesthesia over general

anesthesiaanesthesia Avoidance of airway manipulationAvoidance of airway manipulation Decreased stress responseDecreased stress response Less thrombogenesisLess thrombogenesis Improved bowel motilityImproved bowel motility Less PONVLess PONV Better post op pain controlBetter post op pain control Fast turnoverFast turnover

Advantages of epidural over Advantages of epidural over spinalspinal

Segmental block can be producedSegmental block can be produced Gradual onset so less hemodynamic Gradual onset so less hemodynamic

changeschanges Flexibility in densityFlexibility in density No hole in dura so no spinal No hole in dura so no spinal

headacheheadache

Disadvantages of epidural Disadvantages of epidural compared to spinalcompared to spinal

Slower inductionSlower induction More risk of local anesthetic toxicityMore risk of local anesthetic toxicity Less reliable, not dense, patchyLess reliable, not dense, patchy

The twin theory The twin theory Spinal anesthesia is a safe, cost-Spinal anesthesia is a safe, cost-

effective and reliable but have a effective and reliable but have a finite duration of action and many finite duration of action and many patients will require supplemental patients will require supplemental analgesia. analgesia.

epidural is flexible but has the epidural is flexible but has the disadvantage that the effects of the disadvantage that the effects of the local anesthetics can be delayed local anesthetics can be delayed

using the combined spinal-epidural using the combined spinal-epidural anesthesia there is no more a anesthesia there is no more a question of which is better question of which is better

Epidural and spinal anesthesia are Epidural and spinal anesthesia are indeed related to each other indeed related to each other

Advantages of CSEAAdvantages of CSEA Dense surgical anesthesia via intrathecal route and Dense surgical anesthesia via intrathecal route and

post op pain control via epidural routepost op pain control via epidural route High risk patients are exposed to a gentler High risk patients are exposed to a gentler

sympathectomy sympathectomy Ideal for a "walking" epidural Ideal for a "walking" epidural Provides immediate pain relief especially for Provides immediate pain relief especially for

patients that are close to 2nd stage labor patients that are close to 2nd stage labor Decreased risk of a post dural puncture headache. Decreased risk of a post dural puncture headache.

This is secondary to using a Tuohy introducer This is secondary to using a Tuohy introducer resulting in fewer sticks, decreased dura leak from resulting in fewer sticks, decreased dura leak from pressure of epidural dose and the use of epidural pressure of epidural dose and the use of epidural opioids opioids

Some anesthesiologists feel that the quality of the Some anesthesiologists feel that the quality of the block is superior due to a small seepage of epidural block is superior due to a small seepage of epidural LA into the subarachnoid space LA into the subarachnoid space

Techniques Techniques

The spinal needle through a needle The spinal needle through a needle

techniquetechnique

Techniques (cont)Techniques (cont)

The “back eye” techniqueThe “back eye” technique

Epidural needle with ports for spinal Epidural needle with ports for spinal and epidural.and epidural.

Techniques (cont)Techniques (cont)

The separate needle techniqueThe separate needle technique

Epidural needle is placed after the Epidural needle is placed after the spinal placement is completedspinal placement is completed

Techniques (cont)Techniques (cont)

Eldor needle Technique: an 18g Eldor needle Technique: an 18g epidural needle and a 22g spinal epidural needle and a 22g spinal needle are welded together, both needle are welded together, both serving as introducers for the serving as introducers for the respective needles respective needles

Technique (cont)Technique (cont)

Epidural catheter is placed first and Epidural catheter is placed first and test dosedtest dosed

Possibility of damaging epidural Possibility of damaging epidural cathetercatheter

More time consuming More time consuming Rarely used these daysRarely used these days

IndicationsIndications "to paint the fence" from both "to paint the fence" from both

its sides its sides hip replacement surgery (28.2%)hip replacement surgery (28.2%) hysterectomy (19%)hysterectomy (19%) knee surgery (14.4%), knee surgery (14.4%), Cesarean section (14%), Cesarean section (14%), femur fracture in elderly femur fracture in elderly

patients (7.2%) patients (7.2%) prostatectomy (5.6%) prostatectomy (5.6%) labor analgesia labor analgesia high abdominal and even high abdominal and even

thoracic operations by the thoracic operations by the adjuvant use of an endotracheal adjuvant use of an endotracheal tube ventilation tube ventilation

Pre-requisitesPre-requisites Complete blood pictureComplete blood picture should not be given if platelet count < 50should not be given if platelet count < 50 be careful if between 50 to 99be careful if between 50 to 99 Coagulation profileCoagulation profile Examination of the backExamination of the back Informed consent with full explanation of Informed consent with full explanation of

procedure and possible complicationsprocedure and possible complications Detailed history and examinationDetailed history and examination bleeding abnormality neurological bleeding abnormality neurological

deficitsdeficits Access to fetal monitoring Access to fetal monitoring

Contraindications Contraindications AbsoluteAbsolute

Patient refusalPatient refusal SepsisSepsis Uncorrected hypovolemiaUncorrected hypovolemia CoagulopathyCoagulopathy

RelativeRelative Elevated ICPElevated ICP Prior back injury with deficitPrior back injury with deficit Progressive neurological disease like multiple Progressive neurological disease like multiple

sclerosissclerosis Chronic back painChronic back pain Localized infection at injection siteLocalized infection at injection site

Problems Problems Flow of local anesthetic into the subarachnoid space Flow of local anesthetic into the subarachnoid space

through the perforation produced by the spinal needle through the perforation produced by the spinal needle Inability to perform the epidural catheter test dose Inability to perform the epidural catheter test dose

due to the fact that the epidural catheter is inserted due to the fact that the epidural catheter is inserted after the subarachnoid local anesthetic injection after the subarachnoid local anesthetic injection

Epidural catheter malposition in the subarachnoid Epidural catheter malposition in the subarachnoid space or intravascular with a danger of total spinal space or intravascular with a danger of total spinal

Insertion of the spinal needle through the bent tip of Insertion of the spinal needle through the bent tip of the epidural needle in the needle-through-needle the epidural needle in the needle-through-needle technique there is friction that produces metallic technique there is friction that produces metallic microparticles that can be introduced further into the microparticles that can be introduced further into the epidural space by the epidural catheter insertion epidural space by the epidural catheter insertion

Delay in epidural catheter threading in the needle-Delay in epidural catheter threading in the needle-through-needle technique there is a partial spinal through-needle technique there is a partial spinal anesthesia while using the hyperbaric anesthetic anesthesia while using the hyperbaric anesthetic solution with the need to supplement it further solution with the need to supplement it further through the epidural route. through the epidural route.

Epidural needle or catheter unintentional dural Epidural needle or catheter unintentional dural puncture puncture

Complications Complications Technique related:Technique related:

Headache - Post-Dural Puncture Headache Headache - Post-Dural Puncture Headache Back pain Back pain Injury to nerves Injury to nerves Permanent injury to the spinal cord Permanent injury to the spinal cord Epidural hematomasEpidural hematomas

Local anesthetic dose related:Local anesthetic dose related: Hypotension Hypotension Shivering Shivering Bladder distension Bladder distension Supine Hypotension Supine Hypotension Leg numbness and weakness Leg numbness and weakness