1. COMBINED SPINAL- EPIDURAL ANESTHESIA H.MOEINI ANESTHESIOLOGIST

2. COMBINED SPINAL-EPIDURAL ANESTHESIA first described in 1937 CSE was first described in 1937 by Soresi but has subsequently been modified over the past 30 years Curelaru performed the first combined spinal anesthesia and catheter-based epidural anaesthesia in 1979 the CSE technique is now seeing increasing popularity

3. COMBINED SPINAL-EPIDURAL ANESTHESIA

4. A CSE allows flexibility in a number of clinical settings because the more rapid onset of spinal block compared with epidural anesthesia allows the operative procedure to begin earlier, whereas the epidural catheter still provides both effective postoperative analgesia and allows anesthesia to be extended as the spinal resolves

5. COMBINED SPINAL-EPIDURAL ANESTHESIA This is particularly useful during labor, where opioid and a small dose of local anesthetic may be injected through a small spinal needle to provide rapid analgesia, whereas the epidural catheter can be used thereafter for both analgesia and surgical anesthesia if an operative delivery becomes necessary

6. CSE (COMBINED SPINAL AND EPIDURAL ANESTHESIA) Spinal fast onset high success rate excellent muscle relaxation low toxicity Epidural Epidural – high flexibility – good controllability – prolonged anesthesica – postoperative pain control

7. COMBINED SPINAL-EPIDURAL ANESTHESIA Another significant advantage of CSE in general is: the ability to use a low dose of intrathecal local anesthetic, with the knowledge that the epidural catheter may be used to extend the block if necessary

8. COMBINED SPINAL-EPIDURAL ANESTHESIA The addition of either local anesthetic or saline alone to the epidural space via the catheter compresses the dural sac and increases the block height Epidural volume extension (EVE) and has been shown in cesarean delivery to provide a comparable sensory block to larger doses of intrathecal local anesthetic (with no epidural volume extension) but with significantly faster motor recovery

9. COMBINED SPINAL-EPIDURAL ANESTHESIA This sequential technique also provides greater hemodynamic stability for high-risk patients using a lower initial mass of drug for spinal anesthetic, with subsequent gradual extension of the block if necessary using the epidural

10. COMBINED SPINAL-EPIDURAL ANESTHESIA TECHNIQUE The CSE technique most commonly involves placement of the epidural needle first, followed by either a “needle through needle” technique to reach the subarachnoid space or an altogether separate spinal needle insertion at either the same or different interspace

11. COMBINED SPINAL-EPIDURAL ANESTHESIA TECHNIQUE Some but not all studies have demonstrated greater success and lower failure rates with the separate needle insertion technique This method has the potential advantage of being able to confirm that the epidural catheter is functional before spinal anesthesia is administered, which, although it is time consuming, may be advantageous if the epidural catheter is to be relied upon for anesthesia when the spinal component resolves

12. COMBINED SPINAL-EPIDURAL ANESTHESIA TECHNIQUE Conversely, this method theoretically risks shearing the epidural catheter that is already in situ If a needle-through-needle techniquenis chosen, special CSE kits are available with long spinal needles, some of which can be locked in place for the subarachnoid injection

13. COMBINED SPINAL-EPIDURAL ANESTHESIA TECHNIQUE

14. COMPLICATIONS UNIQUE TO COMBINED SPINAL-EPIDURALS The risk of metal toxicity from abraded spinal needle particles using the needle-through- needle technique has not been confirmed

15. ELDOR NEEDLE TECHNIQUE The Eldor needle (1) was first described in 1990. The Eldor needle is a combined spinal-epidural needle which is composed of an 18 gauge epidural needle with a 20 gauge spinal conduit. This is a specialized needle for the combined spinal-epidural anesthesia. There is no need of long spinal needles. The epidural catheter can be inserted before the spinal anesthetic injection. The Eldor needle facilitates the insertion of very small gauge spinal needles through its spinal conduit, so significantly reduces the incidence of post-dural puncture headache. There is no danger of epidural catheter protrusion through the dural hole made by the spinal needle. There are no metallic particles production while the spinal needle passes through the bent epidural needle tip, as in the needle-through-needle technique. The procedure of the Eldor needle is quite simple and straightforward. First, the spinal needle is introduced into the guide needle as far as the distal end of the latter. Then, the now Eldor needle is introduced into the selected intervertebral space and the epidural space is located using the well-known indicator methods. After that the epidural catheter is introduced into the epidural space, confirming its position by the test dose technique. Then, the spinal needle is slowly pushed in to puncture the dura, until cerebrospinal fluid is obtained. The anesthetic solution is injected through the spinal needle into the spinal space. Subsequently, the spinal needle is slowly withdrawn from the guide needle and then the Eldor needle is withdrawn, leaving the epidural catheter in position in the epidural space.

16. HUBER NEEDLE TECHNIQUE Huber (1), the inventor of the "Tuohy" epidural needle, also patented in 1953 an hypodermic needle with an "auxiliary outlet being disposed in transverse alignment with the channel outlet" (2). Hanaoka (3) described in 1986 its use in 500 patients. This needle has a very small hole behind the epidural needle tip ("back eye"). A small gauge spinal needle is inserted through that hole and punctures the dura. After withdrawing the spinal needle an epidural catheter is introduced through the epidural needle

18. ESPOCAN CSE NEEDLE (B. BRAUN)

20. HANAOKA (1986)