when using cse for any long surgery(lower limb/bladder reconstruction etc) when do u activate the epidural and how do u dose it?what decides the epidural top ups?
Ofcourse you decide when and how to activate the epidural component of CSE
IF we are using CSE for say a long ortho case - we usually give the intial SAB of 3.5 ml of 0.5% bupivacaine and we try to run the case entirely on spinal. we use the epicath for post-op analgesia as needed. In such a case, before shifting the patient out we give an epi topup of 6 to 10 ml of .0625 or .1 % bupi with the desired narcotic ( fentanyl or preservative free morphine or buprenorphine or tramadol) added.
If we use CSE for a very sick patient or Obgyn we give a small dose SAB like 1 to 1.5 ml of 0.5% bupi and after checking the level we immediately start extending the block slowly with titrated doses of 2% ligno given in the epicatheter. We keep giving about 3 - 5 ml and keep checking level. This gives us time to titrate the level slowly upwards and hence time also to adequately treat the slowly developing hypotension. If surgery gets prolonged we switch to 0.25 or 0.125% bupi along with desired narcotics as the need may be.
regds
thanks for giving ur valuable reply.
doing long ortho cases entirely under spinal is sometimes not possible.u have to activate the epidural after some time the block has regressed.then how do u activate the epidural and with what dose?how do maintain the desired level of anesthesia?
We activate the epidural component of CSE intra-operatively depending upon the need of the surgery.
If motor paralysis is necessary to proceed with surgery we go with 0.5% bupivacaine + 2 - 5 mcg/ ml of fentanyl. We usually use fractionated doses of 3 - 5 ml at a time. We monitor the level and add on the drug as necessary to get the desired block level.
IF we need only sensory block we prefer 0.25% bupivacaine with the same strength of Fentanyl and in the same dosaging schedule.
Need to remember that using 0.5% solution tends to produce more hypotension than diluter solutions.
We repeat all top up every 60 to 90 mins depending upon patient needs, haemodynamic stability and progress of surgery
reg
thank u very much.
Hi, for CSE in major cases, we give spinal anaesthesia with BUPIVACAINE 2.5 ml + clonidine 30 microgram or fentanyl 25 microgram, almost for all cases and starts epidural after 60 min with bupivacaine 0.25% + fentanyl 2 microgram/ ml, at the rate of 8 ml/hr infusion. at the end of the sugery before shiftng infusion is converted to bupivacaion 0.1% + fentanyl 1 microgram/ml at 8 ml/hr for first 3 hrs and then 6 ml/hr for rest of the post op period.
I am presonaly very happy with this protocol.
We reduce the dose of intrathecal bupivacaine if pt's cardiac status is compromised.
regards.