Introduction:
The practice of simultaneously administering spinal and epidural anesthesia is known as combined spinal epidural anesthesia (CSE), and it was first recorded in 1937. Complications that are missing from either operation alone may arise when the two techniques are combined.
In recent years, regional anesthesia techniques have been more utilized for postoperative pain control, obstetrics, and surgery. An initial subarachnoid injection, the implantation of an epidural catheter, and the continuing administration of epidural drugs comprise the relatively novel combined spinal-epidural (CSE) anesthetic approach. Starting the spinal medicines quickly and then administering more drugs for protracted anesthesia enables quick pain relief or the induction of regional anesthesia. Furthermore, prolonged delivery of postoperative analgesia through the epidural catheter is possible. Clinical investigations have shown that the CSE approach offers superior surgical conditions with advantages over the traditional epidural block and as fast as a single-shot subarachnoid block.
What Are the Clinical Applications of the Combined Spinal Epidural (CSE) Technique?
General Anesthesia:
The CSE technique, detailed in medical literature, finds application across various surgical fields, including general surgery, orthopedics, trauma surgery of the lower limb, and urological and gynecological surgery. Clinical trials have evidenced its ability to swiftly establish excellent surgical conditions, surpassing those achieved solely with single-shot subarachnoid block and even epidural block. Implementing the CSE technique leads to rapid onset of surgical anesthesia, saving approximately 15 to 20 minutes compared to epidural anesthesia alone. Moreover, it offers the flexibility of supplementing subarachnoid anesthesia with epidural catheterization (catheters placed in epidural space), as highlighted in recent studies such as on laparoscopic appendectomy (surgical excision of the appendix) under CSE anesthesia.
In their approach, spinal anesthesia was administered at the lumbar L2–L3 interspace with a combination of hyperbaric Bupivacaine and Fentanyl, while an epidural catheter was placed at the thoracic vertebrae (T10–T11) interspace for additional anesthesia and postoperative pain management. Additionally, the research suggests that different needle combinations can be employed in the CSE technique, each with its own set of advantages and disadvantages tailored to individual patient needs and surgical needs.
Labor Analgesia:
The combined spinal epidural (CSE) technique is commonly employed in obstetric care to deliver efficient analgesia for women during childbirth. It provides quick pain relief with minimal risk of side effects like toxicity or motor impairment. Moreover, it enables the extension of analgesia duration, often necessary during labor, by utilizing an epidural catheter. Additionally, in case of the need for operative delivery, the same catheter can be utilized to provide anesthesia. Spinal analgesia onset is nearly immediate, lasting between two to three hours, depending on the chosen agents. However, its duration tends to be shorter when administered to women in advanced labor compared to those in early labor. Patients in labor may prefer CSE anesthesia over standard epidurals, possibly due to a heightened sense of control. While initial descriptions of spinal labor analgesia recommended Sufentanil or Fentanyl, combining isobaric Bupivacaine with opioids enhances sensory block density while minimizing motor block. The originally suggested doses of 25 μg (micrograms) Fentanyl or 10 μg (micrograms) Sufentanil have been revised to smaller opioid doses combined with a local anesthetic based on subsequent research.
Cesarean Delivery:
The combined spinal-epidural (CSE) technique, introduced as an option for cesarean delivery in 1984, has recently gained significant popularity. This method offers a quick onset of strong surgical anesthesia while allowing for the extension of the block using an epidural catheter. Furthermore, because the block can be supplemented as needed, the CSE technique permits the initial use of lower doses of spinal local anesthetics, potentially reducing the occurrence of high spinal block or prolonged hypotension (decreased blood pressure). It may also shorten the time spent in the post-anesthesia care unit (PACU). However, challenges associated with the CSE technique for cesarean delivery include the inability to assess the catheter, the risk of an unsuccessful epidural catheter placement following spinal injection, and the potential for increased spread of previously administered spinal medication after employing the epidural catheter.
External Cephalic Version of Breech Presentation:
Neuraxial analgesia has been utilized to alleviate maternal pain during the external cephalic version (ECV) (a procedure utilized to turn a baby from a breech position to a head-down position) for breech presentation. The combined spinal-epidural (CSE) technique offers the advantage of rapid and effective pain relief during ECV, with the possibility of transitioning to neuraxial anesthesia for emergency delivery if necessary. A successful instance of ECV performed under the CSE technique followed by vaginal delivery. The impact of the CSE technique on ECV success compared to systemic opioid analgesia, finding no discernible difference. However, they noted lower pain scores and increased satisfaction with CSE analgesia.
What Are the Indications and Contraindications of Combined Spinal Epidural (CSE) Technique?
Indications:
Some of the indications include patients requiring analgesia and fast anesthesia, followed by prolonged postprocedural analgesia. Because CSE anesthesia provides prompt, dependable anesthetic with sufficient muscle relaxation and low medication toxicity to both the woman and the fetus, it is used in labor analgesia, including both elective and emergency cesarean sections. It has been shown that for abdominal surgeries like hysterectomies, the CSE approach is better than both individual and epidural anesthesia. The anesthetic used for thoracic procedures has been CSE. Respiratory depression and the suppression of cardioaccelerator fibers can need the use of cardioactive medications along with general anesthesia that maintains a secure airway. The use of CSE anesthetic offers advantages for reduced blood loss and decreased incidence for specific lower limb orthopedic surgeries (such as total hip arthroplasty (surgical method to restore joint function), femur fractures, and total knee arthroplasty).
Contraindications:
Refusal from the patient, sepsis, hypovolemia (blood and fluid loss), coagulopathy (hemostasis disruption that causes either excessive bleeding or clotting) or therapeutic anticoagulation, elevated cranial pressure, and procedure-site infection are absolute contraindications. Aortic stenosis (narrowing of the valves in the aorta), dementia (affecting memory and thinking abilities), severe psychiatric illness, blockage of the left ventricle's outflow tract, and modifications to the spinal column resulting from previous surgery are examples of relative contraindications.
What Are the Advantages and Disadvantages of the Combined Spinal Epidural (CSE) Technique?
Advantages:
The ideal CSE anesthetic avoids the drawbacks and combines the benefits of each treatment. Whereas the epidural portion enables prolonged analgesia by repeated doses or continuous infusion of local anesthetic, the spinal portion enables quicker and more consistent blocking. The concentration of the local anesthetic can be changed to change the blockade's intensity. While the preparation time for surgery is longer with CSE anesthesia than with general anesthesia, the approach reduces emesis episodes, recovery time in the postanesthesia care unit, and time for the patient to consume fluids after surgery.
Disadvantages:
The single administration of local anesthetic, uneven and unpredictable levels of blocking with spinal anesthesia, inadequate sacral distribution, and probable local anesthetic toxicity associated with epidural anesthesia are among the potential drawbacks that could be avoided.
Conclusion:
The purpose of CSE block is to prolong analgesia by combining the flexibility of continuous epidural block with the quickness, density, and dependability of subarachnoid block therapy. Many hospitals regularly employ the CSE approach, especially for major orthopedic surgery and obstetrics. The CSE approach has been shown to reduce the occurrence of many other adverse effects related to neuraxial analgesia as well as its failure rate.
