Combined spinal epidural anesthesia

Combined spinal epidural (CSE) anesthesia is a technique that has been accepted readily for care of the obstetrical patient. In a previous report the author discussed the attributes of this technique that make it an increasingly popular choice for care of the surgical patient. CSE has special advantages for the patient undergoing ambulatory surgery. Dose response studies have been useful in determining a reliable short-acting alternative to epidural anesthesia for the ambulatory surgery patient. In fact, CSE with a low dose of lidocaine is a more reliable alternative to chloroprocaine anesthesia, with a very similar onset and offset profile. The preferred technique for CSE anesthesia is presented below with attention to the relevant functional anatomy that must be appreciated to have the technique work on a daily basis with minimal side effects and complications. The practicality of CSE has been questioned and the “failure rate” has been poorly defined in this regional technique that is still in its infancy. The basis of the failure rate of the needle-through-needle technique is discussed as well as practical alternatives that make a 100% success rate obtainable. Finally, the exact technique for needle-through-needle is presented in detail. The security of an epidural catheter allows for minimal dosing of local anesthetic and therefore more precise predictability of day surgery subarachnoid anesthesia.