Combined spinal-epidural (CSE) anesthesia is a neuraxial technique that offers benefits of both spinal and epidural anesthesia and analgesia. The CSE technique involves a subarachnoid injection followed by the placement of a catheter in the epidural space for administration of epidural medications. This permits rapid-onset spinal analgesia, with access for supplementing insufficient subarachnoid anesthesia or prolonging anesthesia and analgesia via the epidural catheter[1]. Though an ongoing debate, many argue that CSE is associated with lower failure rates and fewer adverse events than spinal or epidural anesthesia[2].

Combined spinal-epidural anesthesia
Anesthesia type

Regional

Airway

None

Lines and access

PIV

Monitors

Standard, EKG

Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
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Overview

Indications [2]

  • General, orthopedic, and trauma surgery of lower extremity
  • Urologic and gynecologic surgery
  • Labor analgesia - more rapid onset pain relief and lower failure rates than standard epidural
  • Cesarean section - rapid onset with ability to prolong anesthesia via epidural catheter

Contraindications [3]

Absolute contraindications

  • Patient refusal
  • Localized sepsis
  • Allergy to drugs used in procedure
  • Inability of patient to remain still for injection (risk of neurologic injury)
  • Increased intracranial pressure (risk of brainstem herniation)

Relative contraindications

  • Neurologic: myelopathy or peripheral neuropathy, spinal stenosis, spine surgery, multiple sclerosis, spina bifida
  • Cardiac: aortic stenosis or fixed cardiac output, hypovolemia
  • Hematologic: thromboprophylaxis, anticoagulants, inherited coagulopathy
  • Infection: systemic infection, bacteremia, septic shock

Advantages of CSE

CSE vs. Epidural Anesthesia

CSE vs. Spinal Anesthesia

Epidural Volume Extension (EVE)

Use in High-Risk Patients

Technique

Needle-Through-Needle Technique

Separate Needle Technique

Drug Choices

Risks & Complications

Potential complications

References

  1. Textbook of regional anesthesia and acute pain management. Admir Hadzic, New York School of Regional Anesthesia. New York: McGraw-Hill, Medical Pub. Division. 2007. ISBN 0-07-144906-X. OCLC 70051351.CS1 maint: others (link)
  2. 2.0 2.1 "Combined Spinal Epidural (CSE)". The American Society of Regional Anesthesia and Pain Medicine (ASRA). Retrieved 2022-09-26.
  3. Basics of anesthesia. Manuel, Jr. Pardo, Ronald D. Miller, Ronald D. Preceded by: Miller (Seventh edition ed.). Philadelphia, PA. 2018. ISBN 9780323401159. OCLC 989157369. |edition= has extra text (help)CS1 maint: others (link)