Combined Spinal-epidurals

gaslinq · Apr 1, 2005

I have been doing CSEs (combined-spinal/epidural ) for about 6 years now and I love the technique. Advantages include: 1) immediate onset (this would be a great boon to labor patients); 2) ability to control the level when using hyperbaric solutions (great for labor, orthopedic, and perineal surgery ); 3) less risk of toxicity since you avoid the large volume of local anesthetic needed to get an epidural going. Disadvantages are mostly related to the fact that there is a dural puncture ,i.e., risk of infection, postdural-puncture headache (although unlikely since the spinal needle used is G27 or higher). I have never encountered a case where the catheter was inadvertently inserted into the subarachnoid space through the dural puncture but theoretically it may occur (although how an 18G catheter can enter a 27G puncture is hard to imagine). The operative word here is combined. I like to give just enough anesthetic (0.5-2 cc) through the spinal to get a low level of block then increase the block height by using the epidural. This can be really beneficial in the L&D area when the surgeons are itching to get started. You can give just enough spinal anesthetic for them to catheterize and prep the patient for C-section without inducing hypotension , then give the rest through the epidural. By the time they start cutting, your anesthetic will have set in. Another advantage is that you get the motor block and good muscle relaxation from the spinal plus the post-operative analgesia that can be given through the epidural. Remember ,though, that while the technique may have the benefits of BOTH spinal and epidural it also carries the RISKS associated with both so don't try it until you are proficient with BOTH techniques

If anyone is using them what do you like/dislike about them??? I am mainly looking for experiences related to the labour/delivery area. I am doing a pros/cons paper for my regional pain managament class and would love to hear CRNA/SRNA experiences with them. Thanks.
Tia
SRNA

Skytrane · Apr 1, 2005

CSE for L+D - I don't use this technique for a primip. The analgesia you get with the intrathecal administration of a low dose local anestheic and opioid is phenomenal. They get almost total pain relief. That's a good thing you say. Yes it is, until the intrathecal starts to wear off after several hours. Then when you dose the epidural - the analgesia is not as complete. The patients are not as happy and end up complaining for the rest of the labor. For a primip I use striaght epidural. For multips I use CSE. Both provide excellant analgesia, and patients are very happy with your services.

Just my personal take on the matter.

SmilingBluEyes · Apr 1, 2005

As an L/D nurse, (not CRNA) I have to say this technique IS phenomenal. The patients get almost immediate relief .....and love it. We have one MDA who does this and he gets RAVE REVIEWS from my L/D patients.

allnurses Guide · Apr 1, 2005

We get pretty much immediate relief from our epidurals alone. hmmmm. . . .

steph