Indications and applications of combined epidural-spinal anesthesia

Posted by Doctor Nguyen Thi Hoai Nam - Department of Surgical Anesthesia, Vinmec Central Park International General Hospital

Combined Spinal Epidural (CSE) is an anesthetic method used for surgery in the lower abdomen and lower extremities as indicated by spinal anesthesia alone. Thanks to the rapid and perfect nature of spinal anesthesia combined with the prolonged action of the epidural catheter, this method allows active duration of anesthesia when the spinal anesthetic wears off and is still effective. pain relief after surgery.

According to statistics in Europe, regional anesthesia accounts for 17% of anesthetic procedures. In which 56% is spinal anesthesia, 40% epidural and about 4% is a combination of spinal - epidural. When indicated, regional anesthesia is often preferred over general anesthesia due to its advantages.
CSE is a method of spinal anesthesia combined with epidural anesthesia. Usually, depending on the type of drug used, the duration of the effect of spinal anesthesia lasts 2-3 hours. If the surgery takes longer than originally planned and the spinal anesthetic wears off, the surgery will be interrupted to switch to general anesthesia. This is a disadvantage and will make the patient anxious and increase pain. In the case of CSE, this will not happen because the effect of the epidural is continuously infused, so pain relief is prolonged both during and after surgery. CSE technique is evaluated as having good and stable analgesic quality, significantly limiting unwanted effects if only spinal anesthesia or epidural anesthesia alone.
This combination helps to create a new anesthesia technique, which not only excels in the quality of anesthesia but also brings high economic efficiency. In addition, the epidural catheter is also used to relieve pain 48-72 hours after surgery, suitable for cases requiring physical therapy and to help patients mobilize early after surgery.

2.1. Indications for surgery: Hip replacement Hysterectomy Knee replacement elective cesarean section Femoral combination in elderly patients Open prostatectomy

2.2. Pain relief in obstetrics Indicated when women have a lot of pain, need quick pain relief in normal delivery. CSE technique has the effect of fast pain relief, creating comfort and satisfaction for the mother and helping the mother to have a favorable labor. Combined spinal-epidural anesthesia also helps reduce anesthetic doses, complications, and side effects. Because there is no reduction in motor function, the mother will cooperate better with the doctor during the procedure.
2.3. Contraindications Contraindications for CSE are the same as for spinal and epidural anaesthesia alone. Specifically:
Patient refuses, does not cooperate; Spine pathology: Polio fever, deformity, kyphosis or malformation of the spine; Blood clotting disease and taking anticoagulants; Severe anemia or inadequate volume depletion; Systemic or procedure site infection; Severe heart valve disease.

3.1. Preoperative examination for the patient The patient is given a pre-anaesthetic examination 1 day before surgery to decide on the appropriate method of anesthesia. Encourage and explain the method to the patient to understand and cooperate well, avoid anxiety, scared. Instruct the patient to use the pain scale; Check medical records and add other necessary tests.

Patients will be monitored parameters such as:
Pulse Blood Pressure Electrocardiogram; Breathing rate; SpO2 oxygen saturation. Administer oxygen through a nasal cannula 2-3 liters/min. Then, the medical staff will place a peripheral line with an 18G catheter and give 0.9% NaCl or Ringer Lactate 500 ml before anesthesia.

The doctor washes his hands sterile, wears protective gear and wears surgical gloves; The patient lies on the left side, with the head bowed, the back arched, the legs bent, the knee pressed close to the abdomen or the back arched. Sterilize the anesthetic area with betadine and alcohol 900 Spread the hole and determine the puncture site at the L2-L3 intervertebral fissure and below Local anesthesia with 1% lidocaine intradermal, subcutaneous, and then ligamentous Piercing the Tuohy needle through the skin and syringe using the loss of resistance technique, now often using a water syringe as a test for loss of resistance. Aspiration through the Tuohy needle without blood, CSF Injecting the spinal needle through the Tuohy needle for spinal anesthesia with a 27G needle Withdrawal of the spinal anesthetic needle after the anesthetic has been injected into the subarachnoid space Insert the catheter into the epidural space through the needle Tuohy, catheter tip upward Withdraw the needle and secure the catheter. Insert catheter with bacterial filter Place patient in supine position Monitor level of numbness, leg paralysis and vital signs during and after surgery.

Low blood pressure Slow pulse Drug allergy (uncommon) Local anesthetic poisoning (rare) from injecting large amounts of local anesthetic into the bloodstream Total spinal anesthesia: rare, can occur if an epidural catheter is inserted subarachnoid space, but if the technical process is strictly followed, it can be avoided; Other complications: Headache, vomiting, urinary retention, infection, nerve damage (rare) Currently, Vinmec International General Hospital has applied spinal anesthesia combined with epidural anesthesia. in surgery and treatment, especially in obstetrics with painless delivery, this is also one of the benefits of using the maternity package. Helps patients as well as pregnant women feel no pain, and at the same time minimizes complications compared to other methods of anesthesia and anesthesia. Especially with a system of modern and standard machinery, together with a team of qualified and experienced doctors and nurses, will bring the best results to customers.
Customers can directly go to Vinmec Health system nationwide to visit or contact the hotline here for support.