Modified CSEA With Single Spinal Needle: A New Approach

Prasant Kumar

摘要

Modified Combined Spinal Epidural Analgesia (CSEA) with a 25 G Quincke spinal needle was tried in 200 adult patients subjected for lower abdominal or lower extremity surgery. Needle insertion technique advocated by Ali and Samson was used while identifying epidural space with a thin bore spinal needle. Patient's weight related dose of epidural buprenorphine (4 - 8 ?g kg-1 body weight) was tried . Modified CSEA could be successfully performed in 90% cases. Weight related dose of epidural buprenorphine (0.15-0.30 mg) in this study, offered almost 20 - 24 h post of pain relief in 58.5% cases without any incidence of respiratory depression, pruritus and post dural puncture headache. Modified CSEA advocated in the text is a cost effective and less complication prone alternative technique. Single shot, weight related dose of epidural buprenorphine provides considerably long duration of analgesia therefore need of epidural catheter might be obviated. Introduction Combined spinal and epidural analgesia is commonly performed by Double space (DST) or Single space segment technique (SST). Ability to perform CSEA through single intervertebral space has made SST a popular technique. Despite this advantage SST suffers from certain specific complications, technical problems and of course there is the cost factor.Migration of epidural catheter in subarachnoid space have been reported 1,2 leading to extensive block 3,4. Delayed respiratory depression due to drug entering into subarachnoid space through migrated catheter has also been claimed 5. Metallic flecks getting deposited in the epidural space while using needle through needle technique have raised concern 6. Meningitis 7,8,9, knotting of catheter 1, inadvertent dural puncture with the wide bore Touhy needle 10,11,12 are additional problems with currently practiced CSEA technique . Length of spinal needle 11,13,14,15, site of hole in Touhy needle at the patient end (back vs end hole) and type of spinal (pencil tip vs. Quincke) 16,17,18,19,20,21 are some of the unresolved controversies with arguments in favour and against each point. Precipitous fall in blood pressure due to subarachnoid block before catheter is introduced 22, 23 particularly in Obstetric patients might necessitate immediate resuscitation. In such situation subsequent introduction of epidural catheter becomes impossible 24. Disposable special kit for SST is very costly 25 and may not be affordable to all of us. In order to overcome the cost factor two attempts have been made recently by Indian authors but both appear to be cumbersome for routine clinical use 25,26. Need to develop and accrue the benefits of CSEA through a simpler, cost-effective and less complication prone technique is therefore felt. A prospective pilot study was undertaken to perform CSEA by single space technique using conventional 25 G Quincke needle, which has not been tried before. Materials & Methods This prospective study was conducted in the Department of Anaesthesiology and Critical Care of Tata Motors Hospital, Jamshedpur, which is a multidisciplinary 540 bed general hospital after the permission from the ethical committee of the hospital.200 patients of either sex belonging to ASA grade I & II posted for lower abdominal or lower extremity surgery were included in the study. Patients with bleeding disorder, spinal deformity, local infection and gross obesity were excluded from the study. Method Block was performed in sitting position at L2-4 intervertebral space using No. 25 G Quincke spinal needle. Needle was advanced through an 21G introducer after infiltrating the selected space with 2ml Lignocaine (1%). Epidural space was identified by applying a constant pressure on the plunger of 2ml air filled glass syringe fixed to the hub of spinal needle. Modified insertion technique advocated by Ali and Samson 27 was adopted for ease of identification of the epidural space. According to this technique, the dorsum of the operator's left hand rests on

机译：在200名接受下腹部或下肢手术的成年患者中，尝试了改良的联合硬膜外硬膜外镇痛（CSEA）和25 G Quincke脊柱针。在使用细孔脊柱针识别硬膜外腔时，使用了由Ali和Samson提倡的针头插入技术。尝试了与患者体重有关的硬膜外丁丙诺啡剂量（4-8 µg kg-1体重）。修改后的CSEA可以在90％的情况下成功执行。在这项研究中，体重相关剂量的硬膜外丁丙诺啡（0.15-0.30 mg）在58.5％的病例中提供了约20-24小时的疼痛缓解，没有呼吸抑制，瘙痒和硬膜穿刺后头痛的发生。本文中倡导的改进的CSEA是一种经济有效且不易并发症的替代技术。硬膜外丁丙诺啡的单次剂量，与体重有关的剂量可提供相当长的镇痛持续时间，因此可避免使用硬膜外导管。简介脊柱和硬膜外联合镇痛通常通过双空间（DST）或单空间段技术（SST）进行。通过单个椎间隙执行CSEA的能力使SST成为一种流行的技术。尽管有这种优势，SST仍存在某些特定的并发症，技术问题，当然还有成本因素。据报道，蛛网膜下腔硬膜外导管的迁移1,2导致广泛的阻塞3,4。也有人声称由于药物通过迁移的导管进入蛛网膜下腔而引起的延迟呼吸抑制。5，使用针刺技术时，金属斑点沉积在硬膜外腔引起了人们的关注。6，脑膜炎7,8,9，导管打结1，硬针10,11,12针大口径硬膜外穿刺是目前实践的CSEA技术的另一个问题。脊柱针的长度11,13,14,15，患者末端Touhy针的孔位（背部vs端孔）和脊柱类型（铅笔尖端vs Quincke）16,17,18,19,20,21有一些尚未解决的争论，每个论点都赞成和反对。在引入导管之前，由于蛛网膜下腔阻塞导致血压急剧下降[22，23]，尤其是在产科患者中，可能需要立即进行复苏。在这种情况下，随后不可能引入硬膜外导管24。用于SST的一次性专用工具包非常昂贵25，而且我们所有人可能负担不起。为了克服成本因素，印度作者最近进行了两次尝试，但对于常规的临床应用而言，两者似乎都很麻烦25,26。因此，需要通过一种更简单，成本效益高且不易发生并发症的技术来开发和累积CSEA的益处。进行了一项前瞻性的初步研究，以使用传统的25 G Quincke针通过单空间技术执行CSEA，此前尚未尝试过。材料与方法本前瞻性研究是在詹谢普尔塔塔汽车医院的麻醉学和重症监护部门进行的，该医院是一家多学科的540张病床的综合医院，经该医院伦理委员会批准。200名男女患者均属于ASA研究包括下腹部或下肢手术的I级和II级。该研究排除了出血性疾病，脊柱畸形，局部感染和肥胖症患者。方法使用No. 25 G Quincke脊柱针在L2-4椎间隙处的坐姿进行阻滞。用2ml利多卡因（1％）渗入选定的空间后，将针头通过21G导引器推进。硬膜外腔是通过在固定于脊柱针接口的2ml充气玻璃注射器的柱塞上施加恒定压力来确定的。阿里和萨姆森（Ali and Samson）27提倡采用改良的插入技术，以易于识别硬膜外腔。根据此技术，操作员左手的背部靠在

Modified CSEA With Single Spinal Needle: A New Approach

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