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In recent years, regional anesthesia techniques for surgery, obstetrics, and postoperative pain management have been used with increasing frequency.1–3 The combined spinal–epidural (CSE) technique, a comparatively new anesthetic technique, includes an initial subarachnoid injection followed by epidural catheter placement and administration of epidural medications. This allows for almost immediate relief of pain or induction of regional anesthesia by the rapid onset of the spinal drugs, and subsequent administration of medications for prolonged anesthesia. In addition postoperative analgesia via the epidural catheter can be delivered for extended periods.

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Clinical studies have demonstrated that the CSE technique provides excellent surgical conditions as quickly as the single-shot subarachnoid (SSS) block, and with advantages compared with the epidural block alone.4–6 The introduction of CSE anesthesia offers benefits of both spinal and epidural anesthesia.

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Although the CSE technique has become increasingly popular over the past two decades, it is a more complex technique that requires comprehensive understanding of epidural and spinal physiology and pharmacology.

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This chapter discusses the technical aspects, advantages, potential complications, and limitations of the CSE technique for surgery and analgesia during labor.

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The results of a recent survey demonstrate wide variation in CSE use and practice among experienced anesthesiologists,7 reflecting concern over the frequency of CSE-related complications,8,9 controversy over the technique,10,11 and the potential for higher failure rates with CSE than with individual spinal or other anesthetic techniques.12

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General Surgery

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In the literature, the technique has been described for use in general, orthopedic, and trauma surgery of lower limb, as well as in urologic and gynecologic surgery. Clinical studies have demonstrated that the CSE technique provides excellent surgical conditions as quickly as with SSS block—conditions that are better than with epidural block alone.4,13 With the CSE technique, surgical anesthesia is established rapidly, saving 15–20 min compared with epidural anesthesia. Furthermore, epidural catheterization provides the possibility of supplementing subarachnoid anesthesia, which may be insufficient when used alone. In a recent article it was also observed that various needles can be used in different combinations when performing CSE and may have different advantages and disadvantages for different patients and situations.14 This will be discussed later in the chapter.

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Labor Analgesia

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The CSE technique is widely used in obstetric practice to provide optimal analgesia for parturients. It offers effective, rapid-onset analgesia with minimal risk of toxicity or motor block.15 In addition, this technique provides the ability to prolong the duration of analgesia, as required, through the use of an epidural catheter. Furthermore, should an operative delivery become necessary, that same catheter can be used to provide operative anesthesia. The onset of spinal analgesia is almost immediate, and the duration is between 2 and 3 h, depending on which agent or agents are chosen. The duration of spinal analgesia, however, decreases when ...

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