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The combined spinal epidural technique allows combining:
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- Rapid onset and dense block from the spinal anesthesia
- Presence of an epidural catheter to prolong block (if surgery outlasts spinal anesthesia) and/or for postoperative analgesia
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- Epidural kit
- Spinal needle long enough to exit epidural needle (24–27 gauge pencil-point needle: Whitacre, Sprotte, or Gertie Marx)
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- Higher concentration to maintain dense block for surgical anesthesia
- Lower concentration for postoperative analgesia
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See chapters 122 and 162 for additional information.
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- After sterile prep, drape, and local infiltration of skin:
- Advance epidural needle into epidural space using loss of resistance technique
- Advance spinal needle through epidural needle into subarachnoid space
- Verify free-flowing CSF and inject spinal medication
- If persistent pain or paresthesia when needle “pops” into subarachnoid or on injecting local anesthetic, withdraw and redirect needle. Do not inject local anesthetic onto nerves or cord:
- It is useful to ask patient which side the paresthesia was felt and redirect needle in the opposite direction (especially with spine deformities)
- Remove spinal needle
- Thread epidural catheter and secure 3–5 cm into epidural space
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See Also Section “Pearls and Tips” in Chapters 122 and 123.
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- Use of saline to detect epidural space may lead to confusion of saline for CSF when spinal needle placed. Prefer LOR to air
- The risk of threading the epidural catheter into dural hole created by spinal needle is minimal if 25 gauge or smaller spinal needle used
- Epidural drugs should be administered and titrated slowly in small increments because of possible intrathecal injection. Dural hole may increase flux of drugs into CSF and enhance their effects
- Incidence of dural puncture (“wet tap”) from epidural needle may be lower with CSE than with epidural technique alone
- Incidence of failed epidural lower with CSE than with epidural alone