Details
Category: Volume 07 Issue 05 May 2019
Hits: 1246

Title: Paramedian Epidural with Midline Spinal in the Same Intervertebral Space: An Alternative Technique for Combined Spinal and Epidural Anaesthesia

Authors: Manisha Sharma, Manish Anand, Nand Kishore, Waquas Ahmed

 DOI: https://dx.doi.org/10.18535/jmscr/v7i5.146

Abstract

Background & Aim: The combined spinal epidural technique (CSE) involves subarachnoid blockade and epidural catheter placement in procedure. Aim was to compare two different approaches of CSE, paramedian epidural with midline Subarachnoid block, that is Single space dual needle technique (SDT) with the Single space technique (SST).

Materials and Methods: The study was randomised, comparative &prospective. A total of 80 patients were divided in Group I SST & Group II SDT. Inclusion criteria: ASA grade I/II, undergoing Hysterectomy etc. Exclusion criteria: Patient refusal, allergy, coagulopathy, IHD, local infection etc. Group I- Needle through needle technique. Group II-Epidural in paramedian position with midline spinal. Parameters observed were technique performance time, time to surgical readiness, in Epidural block: attempts for space localisation, accidental dural puncture. For epidural catheter: attempts for insertion, presence of blood / CSF, paraesthesia, inability to push test dose. While Subarachnoid block; attempts, appreciation of dural puncture, reflux of CSF < 5 seconds.

Results: Both were comparable in technique performance time & time to surgical readiness. Parameters relating to epidural block were comparable.The appreciation of dura in SAB in group I was 26 and group II was 39(p 0.0002) which was statistically significant. The incidence of reflux of CSF within 5 seconds in the group I was 33 and group II was 40 which was statistically significant (p 0.0056).

Conclusion: Paramedian epidural with midline spinal at the same space is an acceptable alternative to the Single Space technique.

Keywords: Paramedian, Epidural, Spinal, Midline.

References

  1. Corning, JL. Spinal anaesthesia and local medication of the cord. N Y Med J. 1885; Vol. 42: 483.
  2. Stevens DS, and W. T. Edwards. Management of pain in intensive care settings. Surgical Clinics of North America. 1999; v. 79, no. 2, p. 371-386.
  3. Cook, T. M. Combined spinal-epidural techniques. Anaesthesia. 2000; 55(1): 42-64.
  4. Rawal, N., B. Holmstrom, J. A. Crowhurst, and Z. A. Van. The combined spinalepidural technique. Anesthesiol. Clin. North America. 2000; 18(2): 267-295.
  5. Norris M, Grieco W et al. Complications of labour analgesia: Epidural versus combined spinal epidural techniques. Anesthesia Analgesia. 1994; 79: 529-37.
  6. Holmstrom B, Rawal N, et al. Risk of catheter migration during combined spinal epidural block: Percutaneous epiduroscopy study. AnaesthAnalg. 1995; 80: 747-753.
  7. Eldor J, Guedj P, Levine S. Delayed respiratory arrest in combined spinal-epidural anesthesia: Case report. RegAnesth. 1994 Nov-Dec; 19(6): 418-22.
  8. Editor J. Metallic fragments and the combined spinal epidural technique. Br J Anesth. 1992; 69: 663.
  9. Cascio M, Heath G. Meningitis following a combined spinal epidural technique in a labouring term parturient. Can J Anaesth. 1996 Apr; 43(4): 399-402.
  10. Morgan BM, Kadim MY. Mobile regional analgesia in labour. British Journal of Obstetrics and Gynaecology. 1994; 101: 839 841.
  1. Levin A, Segal S, Datta S. Does combined spinal–epidural analgesia alter the incidence of paraesthesia during epidural catheter insertion? Anesthesia and Analgesia. 1998; 86: 445–51.
  2. Kestin IG. Spinal anaesthesia in obstetrics. British Journal of Anaesthesia. 1991; 67: 663.
  3. Blomberg RG. Technical advantages of the paramedian approach for lumbar epidural puncture and catheter introduction: A study using epiduroscopy in autopsy patients. Anaesthesia. 1988; 43: 837–43.
  4. Satoki Inoue, Masahiko Kawaguchi, Hitoshi Furuya. Cephalad Angulation of Epidural Needle Insertion May Be an Important Factor for Safe Epidural Space Approach: a Mathematical Model. Rev Bras Anestesiol. Clinical information. 2011; 61: 6: 764-769.
  5. D. and Wason R. Paramedian epidural with midline spinal in the same intervertebral space: An alternative technique for combined spinal      and epidural anaesthesia Indian Journal of Anaesthesiology. 2013; 57(4): 364-370.
  6. Takahashi R, Yamada K, Yoshiyama T, Nitta S, Hamatani K. Comparison of double-segment technique with single-space technique for cesarean section using combined spinal epidural anesthesia. Masui. 1999; 48: 57-61.
  7. Leeda M, Stienstra R, Arbous MS, Dahan A, Th Veering B, Burm AG, et al. Lumbar epidural catheter insertion: The midline vs. the paramedian      approach. Eur J Anaesthesiol. 2005; 22: 839-42.
  8. Casati A, D´Ambrosio A, Negri PE, Fanelli G, Tagariello V, Tarantino F. A clinical comparison between needle-through-needle and double segment-techniques for combined spinal and epidural anaesthesia. RegAnesth Pain Med. 1998; Jul-Aug; 23(4): 390-4.
  9. Paech MJ, Evans SF. Prospective clinical evaluation of two combined spinal-epidural kits. Anaesth Intensive Care. 1995; 23: 600-4.
  1. Waldman SA, Liguori GA. Comparison of the flow rates of 27-gauge Whitacre and Sprotte needles for combined spinal and epidural anesthesia. RegAnesth. 1996; 21: 378-9.

Corresponding Author

Manish Anand

Consultant, Heart Hospital, Kankerbagh, Patna, Bihar, India