My
Ideas
My
Ideas
Combined spinal epidural(CSE) or 2-in-1 block is a useful regional technique for inpatients,outpatients and painless labors. It needs a special kind of equipment which costs more money. Having realized this limit,I modified the routinely used IV needles,namely Jelco@ # 16,spinal needle B-D@ # 25-27 and epidural catheter Portex@ # 16-18 as in Figure 1.
Figure 1
5% Hyperbaric Lidocaine,2% plain Lidocaine,2% Lidocaine with Epinephrine 1:80,000 ,epidural catheter Portex@# 18,IV catheter Jelco@# 16 and spinal needle B-D@# 25
The procedure is done like a normal block : after positioning the patient in lateral decubitus either right or left,cleaning the lumbar area with antiseptic,and putting the drape,I infiltrate the skin with local anesthetic agent [enough for large-bore needle] at L2-3 or 4-5 as Figure 2.
Figure 2
Local infiltration at L2-3 or 4-5 midline
I put in the IV catheter Jelco@# 16 as Figure 3 [make sure that the plastic sheath can be passed over the metallic stylet smoothly before insertion].
Figure 3
Jelco@# 16 insertion gently
Connected with a 5-ml or 10-ml glass syringe,the needle is advanced further until the epidural space is reached by loss of resistance technique as Figure 4.
Figure 4
Using loss of resistance to find the epidural space
Then the needle is pushed a little deeper for plastic sheath cannulation. Do not be too afraid that it will penetrate the subarachnoid space. Withdraw the metallic stylet while insert the plastic sheath into the epidural space as Figure 5.
Figure 5
Cannulation the plastic sheath into the epidural space and withdrawing the metallic stylet
Test loss of resistance again via the plastic sheath. To do spinal block,pass a spinal needle B-D@# 25 through the plastic sheath [ this will encounter the resistance of dura only]. After CSF appearance,inject 5% hyperbaric Lidocaine 0.9-1.5 ml [dose varies depending on expected level of blockade,epidural dose and experience] as Figure 6.
Figure 6
Passing the spinal needle B-D@# 25 through the plastic sheath of Jelco@# 16
After spinal block,thread the epidural catheter through the plastic sheath as usually done with Touhy needle as Figure 7.
Figure 7
Threading the epidural catheter through the plastic sheath with the curve of the catheter upward
Withdraw the plastic sheath and tape the catheter securely on the patient's back as Figure 8.
Figure 8
Withdrawing the plastic sheath while inserting the catheter
Before epidural injection,aspirate and test 3 ml 2% Lidocaine with Epinephrine 1:200,000 and wait for any accidents. I can halve the normal epidural dose in CSE.
My uses of 2-in-1 block :
1. normal regional anesthesia : to faten the onset and prolong duration of blockade
2.outpatient cases : halve the spinal dose and bolus half the epidural dose [ it is possible to bolus without epidural catheter]
3. painless labor : spinal Fentanyl 25-50 microg and epidural 0.125% Bupivacaine with Fentanyl 50 microg
I do not suggest in obese patients because the plastic sheath is too short to reach the epidural space. The patient should lie still,flexing the spine or the plastic sheath will be kinked. I found that accidental spinal puncture was not frequent if the technique was gently done. My clinical trial on more than 100 patients was on Dr Joseph Eldor's.
I experienced some new insight in how theses regional techniques work. So it is worth trying,especially when the expensive set of equipment is not affordable.