CSE

Question 2

History and Development: What year was CSE first described and by whom?

Answer 2

1937, Soresi described the sequential injection of LA, first into the epidural space then into the subarachnoid space using the same small gauge spinal needle. He used this technique in over 200 patients. Stated “by combining the two methods many of the disadvantages of both methods are eliminated and their advantages are enhanced to an almost incredible degree.”

Question 3

In what surgeries is CSE currently being used?

Answer 3

Orthopedic Urologic Gynecologic Also being used for providing post-op pain relief

Question 4

Why has the CSE gained much favor in obstetrics?

Answer 4

Because it provides ANALGESIA & ANESTHESIA for labor, delivery or for C-sections.

Question 5

What are the advantages of CSE?

Answer 5

CSE anesthesia & analgesia offers the advantages of both techniques It can be used in any situation where spinal or epidural is planned It offers the “quick” onset of a spinal with the “flexibility” of an epidural catheter for prolonged procedures and/or post-op pain relief

Question 6

History and Development: In 1979, how did Curelaru provide CSE to more than 150 patients?

Answer 6

He used a two puncture technique. First he placed an epidural catheter, then he performed the subarachnoid injection one or two interspaces lower

Question 7

History and Development: Advantages of the technique included:

Answer 7

“the possibility of obtaining a high quality conduction anesthesia, virtually unlimited in time, minimal toxicity and the absence of postoperative pulmonary complications.” sorry, not sure how to have asked that question better

Question 8

History and Development: Disadvantages of the technique included:

Answer 8

“the need for two verterbral punctures, a longer time for onset of anesthesia and difficulty finding the subarachnoid space after catheterization of the epidural space.” again, sorry

Question 9

History and Development: In 1982 Coates, Mumtaz, and colleagues reported using what?

Answer 9

A single space technique in which a long spinal need was inserted through the epidural needle to provide the spinal component of the CSE technique

Question 10

History and Development: What were the advantages and disadvantages that Coates et al described of their new technique?

Answer 10

Reported the technique was “simple, reliable and quick to perform” but was concerned with the possible passage of the epidural catheter through the hole in the dura and the possible subarachnoid injection of the epidural medication with a resultant high block or total spinal. Were also concerned with the creation of metal particles by the two needles rubbing together and these particles being introduced to either or both of the subarachnoid and/or epidural spaces

Question 11

History and Development: Because of concerns raised with the Coates et al technique, what was developed?

Answer 11

The design of a type of needle that has TWO channels in one needle with one dedicated for the epidural catheter and the other dedicated for the spinal needle.

Question 12

History and Development: What was the pitfall of the double channel needle designed for CSE? What did this lead to?

Answer 12

The double channel needle proved to be fairly large in diameter and was leading to significant tissue trauma and backache post procedure Other needles began to be developed (including the ones used today)

Question 13

What is the most common needle used today for CSE?

Answer 13

A modified Tuohy needle with a “back eye” located at the bend of the needle

Question 14

Review of epidural needles and their tips

Question 15

Obstetric CSE dose typically used is reduced to?

Answer 15

2-4 mg

Question 16

Name 5 types of spinal needles?

Answer 16

Quincke-Babcock Pitkin Greene Whitacre Tuohy

Question 17

How does the CSE needle compare to the epidural needle?

Answer 17

The needle used for CSE is designed to be slightly longer than the epidural needle used (typically 4.5 inch spinal needle)

Question 18

History and Development: The other needle used today is a straight beveled, blunt tipped needle. What is it called? What is the disadvantage of this type of needle?

Answer 18

Crawford. There is a higher incidence of inadvertent dural puncture during placement since it is NOT rounded like the Tuohy. Side note: about 70% of kits have the modified Tuohy and the other 30% have the straight beveled blunted epidural needle.

Question 19

Describe the TWO-Level technique

Answer 19

The epidural catheter is inserted FIRST and tested so placement is confirmed Then the spinal is done at one or two interspaces below the level of the epidural

Question 20

What is the advantage to the two-level technique?

Answer 20

Able to test epidural catheter prior to spinal injection

Question 21

What is the disadvantage to the two-level technique?

Answer 21

Trauma and discomfort from mutlilevel insertion

Question 22

Describe the single level insertion technique.

Answer 22

First used in 1982, the “needle-through-needle” technique involves inserting an epidural needle at the appropriate interspace then using the epidural needle as a guide or introducer for the spinal needle. A small 25 or 27 gauge spinal needle can be used since the epdiural needle is its guide and the tissue has already been penetrated by the first needle

Question 23

What is the advantage of the single level insertion technique?

Answer 23

It is associated with less tissue trauma, backache and associated morbidity

Question 24

What is the disadvantage to the single level insertion technique?

Answer 24

Inability to be able to adequately test the epidural catheter position and function with a pre-existing spinal block since the spinal part of the procedure must go first.

Question 25

For single level insertion: Once your epidural catheter is placed, ANY FLUID aspirated from it must be assessed to see if it is CSF. How are some ways you know it is CSF?

Answer 25

CSF is warm to the touch if allowed to drip on your forearm (even gloved with thin latex) CSF will form a precipitate if mixed with an equal volume of sodium thiopental

Question 26

ANY injection via the catheter must ONLY BE DONE after careful and diligent test aspirations, how often do you need to aspirate while giving your epidural doses?

Answer 26

you need to aspirate every 3-5 cc while giving your epidural doses

Question 27

What must be avoided with single level insertion?

Answer 27

Insertion of the epidural catheter through your spinal hole must be avoided and detected at all costs.

Question 28

Why is it so important to avoid/detect insertion of the epidural catheter through your spinal hole?

Answer 28

Because the effect of injection of your epidural dose into the CSF can lead to a total spinal

Question 29

Once the spinal is done, what must you reassess?

Answer 29

The epdiural needle placement to re-confirm LOR and appropriate needle tip placement

Question 30

A CSE is one situation in which your epidural dose SHOULD be given via the catheter rather than the needle. Explain why.

Answer 30

Your needle is right in front of the hole you just made in the dura so any positive pressure of LA through the needle may go right through the hole and become subarachnoid and again lead to a high block or total spinal.

Question 31

Who described the single level “sequential” technique and what is its advantage?

Answer 31

Rawal and it was designed to minimize the hypotensive effects of the spinal portion of the CSE

Question 32

Describe the single level “sequential” technique.

Answer 32

An epidural needle is placed at the selected intervertebral space and a low dose of spinal anesthetic is given 7.5 mg of hyperbaric bupivacaine The epidural catheter is placed as quickly as possible and the patient is placed supine again, ASAP Once the spinal dose has set in and the level is determined, the catheter is used to titrate the dose higher until the desired effect is obtained 1.5-2 cc per unblocked segment

Question 33

What are the disadvantages of the single level “sequential” technique?

Answer 33

Time consuming and you are really only using each technique to half its potential and risking all the possible side effects and complications

Question 34

Name 2 agents used for the spinal component for a CSE.

Answer 34

Lidocaine 5% hyperbaric Bupivacaine 0.75% hyperbaric

Question 35

Name three agents used for the epidural component of a CSE.

Answer 35

Lidocaine 2% with or without epi Bupivacaine 0.25-0.5% plain Chloroprocaine 2-3% plain

Question 36

CSE is the main technique employed in what “kind” of epidural? What agent is typicaly used to accomplish this an minimize motor blockade?

Answer 36

The “walking” epidural. 0.0625% Bupivacaine via the epidural catheter Side note: medico-legal issues have allowed the walking epidural to fall in popularity

Question 37

Current Technique: The CSE technique offers which advantages over conventional epidural analgesia/anesthesia? (2)

Answer 37

Rapid onset of the intrathecal component for women who are in the later stages of labor and who are in significant pain The use of intrathecal opioids in early labor provides pain relief with possible minimal to absent motor block and allows the patient to ambulate

Question 38

Describe the current CSE technique

Answer 38

It involves the placement of an epidural needle at the selected interspace (usually L3-L4 or L4-L5) Once the epidural is placed it is followed by the passage of the spinal needle in the “needle-through-needle” technique Intrathecal dose injected Epidural catheter is then passed and the epidural needle is withrdrawn and the catheter is secured in place by 2’ silk tape or “Hypo-fix” tape (paper tape in tape-allergic patients) The epidural catheter can be activated at any time that supplemental analgesia/anesthsia are needed

Question 39

Current technique: Once the spinal needle is passed, usually what and how much is injected intrathecally?

Answer 39

Fentanyl 10-25 mcg with or without a small dose of bupivacaine (2.5 mg) or preservative-free NS

Question 40

Current technique: When the epidural catheter is activated, what agent and how much is usually used?

Answer 40

0.125-0.25% bupivacaine followed by initation of an infusion of 0.0625-0.125% bupivacaine at 10-12 cc/hr (with or without opioids)

Question 41

Current Technique: Should the need to convert to a C-section, what are the steps you should take?

Answer 41

After careful aspiration of the catheter, a test dose of 3 cc of 1.5% lidocaine w/epi is given After a negative test dose, incremental doses of one of the following can be given to establish a sufficient level of anesthesia lidocaine 2% bupivacaine 0.5% chloroprocaine 3%

Question 42

Current Technique: Concerns related to the use of CSE exist. For example, the ability of the patient to safely ambulate following intrathecal opioid administration. Explain further.

Answer 42

There is tremendous individual variation in the responses experienced by patients ranging from no changes in motor function to a significant level of weakness sufficient to keep them in bed for their entire labor. The mechanism is not completely understood but a significant part relates to sudden hypotension following intrathecal opioid administration (NOT good to have pregnant women falling in the hallways while in labor!!!!)

Question 43

Current Technique: Another concern are the possible complications that can occur with CSE. Name these possible complications (6)

Answer 43

Failure to obtain a subarachnoid block (needle too short) Catheter migration (through dural puncture hole) Metallic particles (needle through needle) Post-dural puncture headache Infection (higher incidence than spinal or epidurals) Neurological injury due to masking of parasthesias by the subarachnoid block caused by the epidural cathether

Question 44

There are advantages and disadvantages to using CSE. Why is the selling point of a “walking” epidural loosing ground?

Answer 44

Liability issues. You expose yourself to complications from BOTH procedures while really never utilizing one technique fully; probably better to use one or the other to its full extent.