The combined spinal epidural analgesia (CSE) technique was first described approximately 60 years ago and came into favor approximately 20 years ago. Most commonly, the technique is performed by inserting an epidural needle into the epidural space, then inserting a long spinal needle into the subarachnoid space. Then, the spinal medication is injected and the epidural catheter is inserted through the epidural needle, once the spinal needle is removed. CSE offers the certainty and speed of onset of spinal analgesia with the flexibility and continuity of an epidural catheter. The major disadvantage is the additional potential for complications introduced by the deliberate dural puncture.
The spinal component usually consists of a small dose of fentanyl (12.5-25 |xg) combined with 0.5-1.0 mg of bupivacaine made up to a volume of 1 ml with saline. This combination will provide 60-90 min of analgesia with little or no motor blockade. The epidural infusion may be started immediately or when the patient complains of returning pain. Most anesthesiologists will consider CSE for patients requesting very early epidural analgesia (<1 cm cervical dilatation) or for those requesting analgesia late in the first stage of labor.
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