CSE (Combined Spinal-Epidural) vs Epidurals in Laboring Patients leads to increased C Sections

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In summary, CSE analgesia was associated with a higher risk of nonreassuring FHR tracings compared with epidural analgesia. Our analysis does not rule out that CSE compared with low-dose epidural bupivacaine analgesia is associated with a higher rate of nonreassuring FHR abnormalities. It is not clear whether this potentially higher incidence is associated with a greater risk of cesarean delivery for the indication of nonreassuring FHR. Further study is required.
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The Effect of Combined Spinal–Epidural Versus Epidural Analgesia in Laboring Women on Nonreassuring Fetal Heart Rate Tracings: Systematic Review and Meta-analysis Judith Hattler, MD,* Markus Klimek, MD, PhD, DEAA, EDIC,† Rolf Rossaint, MD, PhD,‡ and Michael Heesen, MD, PhD*


BACKGROUND: Combined spinal–epidural labor analgesia has gained popularity, but it is unclear whether this technique is associated with a higher incidence of nonreassuring fetal heart rate (FHR) tracings compared with epidural analgesia. Our meta-analysis aimed at comparing the incidence of nonreassuring FHR tracings between the 2 neuraxial techniques.

METHODS: Databases were searched to identify randomized controlled trials that compared the incidence of nonreassuring FHR tracings, as defined in the individual studies, after combined spinal–epidural versus epidural analgesia in laboring women. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using the random-effects model. We performed a subgroup analysis for studies using low-dose epidural bupivacaine concentrations (≤0.125%) for epidural analgesia. RESULTS: Seventeen trials including 3947 parturients were retrieved that compared the 2 neuraxial techniques. All trials used intrathecal opioids in 1 study arm. The pooled effect estimate of low- and high-dose epidural bupivacaine studies together showed a significantly increased risk of nonreassuring FHR tracings with the combined technique (RR 1.31, 95% CI 1.02–1.67, P = .03, I2 = 18%). A subgroup analysis of 10 trials using low-dose epidural bupivacaine found a RR for nonreassuring FHR tracings between combined spinal–epidural and epidural analgesia of 1.12, 95% CI 0.93–1.34, P = .18. In a sensitivity analysis of those low-dose epidural bupivacaine studies that ensured blinding of the outcome assessor, the RR was 1.41, 95% CI 0.99–2.02, P = .06.

CONCLUSIONS: Combined spinal–epidural labor analgesia was associated with a higher risk of nonreassuring FHR tracings than epidural analgesia alone. In the subgroup analysis comparing combined spinal–epidural with low-dose epidural labor analgesia, the 95% CI contains a clinically significant difference between groups; moreover, the 95% CI overlaps with the 95% CI of the comparison of the combined low- and high-dose epidural techniques. Therefore, it cannot be concluded that there was no difference between combined spinal–epidural and low-dose epidural techniques. (Anesth Analg 2016;XXX:00–00)
 
CSE is very popular at Wake Forest for patients that are not Pre-E and uncomplicated prenatal history. The explanation I've heard is that the late decels are transient and resolve after a couple of boluses of ephedrine.
 
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While it still qualifies as anecdata, I've done about 1200 CSEs since I finished residency with zero stat c sections following them. I do place straight epidurals if there is a shady FHR tracing, maybe 1-2% of the time. Full disclosure: I did spend a month at Wake doing OB anesthesia as a resident.


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My experience is in line with B-bones. I'm a CSE everyone kind of guy. Trust me, if I was having to wisk people off to the OR for stat C/S's I woulda stopped doing them long ago.
 
My wife had bilateral femoral neuropathy after CSE with our first son. Took her one year to be able to run again. It's likely that 3.5 hours of pushing in a hyperflexed position was the true cause, but the spinal prevented her from realizing that it was a bad position to stay in for so long. She did deliver vaginally, no C/S needed. Apparently her mom had a "bad reaction" to a CSE as well, although she didn't tell me until after and she doesn't know the details of what happened.

Just delivered second baby boy this week with a straight epidural, no neuropathy, worked like a charm. My wife's experience is certainly rare, but I haven't done OB yet and I am already wary of CSE as a result.
 
rakotomazoto said:
My wife had bilateral femoral neuropathy after CSE with our first son. Took her one year to be able to run again. It's likely that 3.5 hours of pushing in a hyperflexed position was the true cause, but the spinal prevented her from realizing that it was a bad position to stay in for so long. She did deliver vaginally, no C/S needed. Apparently her mom had a "bad reaction" to a CSE as well, although she didn't tell me until after and she doesn't know the details of what happened.

Just delivered second baby boy this week with a straight epidural, no neuropathy, worked like a charm. My wife's experience is certainly rare, but I haven't done OB yet and I am already wary of CSE as a result.
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Spoken like true OB or midwife. 1. Spinals don't last 3.5 hrs. 2. The physicians in the room should have been paying attention to positioning... especially in the setting of quality neuraxial analgesia. Blaming the spinal is a scapegoat for their error.

Don't blame the spinal.
 
"My back still hurts where I got my epidural 4 years ago. It pulls when I run and it gets a stabbing sensation like they're putting the needle in again."
... Ok...
I like CSEs and have done hundreds. They all get NR FHT, for about 120 seconds.
Don't do many anymore 2/2 the nature of my current practice.


--
Il Destriero
 
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What was the spinal dose in these studies. I rarely see NR FHT's. But I don't really stick around long enough to observe either. Never had one go to CSE for it though. I also, insist on a good bolus. If a bolus isn't adequate I do a straight epidural.
 
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I use 1cc of the. 25% bupi. The real answer is bolus through the Touhy needle...... I have never had a stat c section bolusing through it...... My dose is 5cc of. 25% bupi through needle then pass catheter then test catheter then 3-5 more cc of. 25% rarely do I get calls on my epidurals.
 
SaltyDog said:
2.5cc of the bag solution (1/8% Bupi + fent 2mcg/mL)
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I like this. Never heard of it, but seems easy and doesn't involve accounting for additional narcotics.

I'm a 1 cc 0.25% bupi/15 mcg fentanyl kind of guy, but I'll give this a try.
 
B-Bone said:
I like this. Never heard of it, but seems easy and doesn't involve accounting for additional narcotics.

I'm a 1 cc 0.25% bupi/15 mcg fentanyl kind of guy, but I'll give this a try.
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I ripped off my technique from the guys at the local OB hospital. I squirt 15-20cc of bag solution into the epidural tray and use that for everything: skin local, LOR, IT dose, and then 2-5cc through the cath
 
Back in the day I used to use 1cc of 0.25% + 20mcg fent + 150 mcg morphine + epi. They often had a mild decel that seemed related to how much pain they seemed to be in.
I started with Sufenta (7.5mcg), but they always had a decell sometimes significant and panic ensued. I think it was a better block though. It was also a PIA to get.


--
Il Destriero
 
B-Bone said:
I like this. Never heard of it, but seems easy and doesn't involve accounting for additional narcotics.

I'm a 1 cc 0.25% bupi/15 mcg fentanyl kind of guy, but I'll give this a try.
Click to expand...


I think you lose some sterility in pulling from the bag plus our bags are usually preloaded in pumps by RNs. Unlockimg bag from pump would slow process down. Also, those doses seem a little light.

I do like CSEs but this study makes you think a bit.
 
narcusprince said:
I use 1cc of the. 25% bupi. The real answer is bolus through the Touhy needle...... I have never had a stat c section bolusing through it...... My dose is 5cc of. 25% bupi through needle then pass catheter then test catheter then 3-5 more cc of. 25% rarely do I get calls on my epidurals.
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Yep. That's what I do when I don't want to do a CSE. But I use 10cc of 0.125% bupiv.
 
Lurch said:
I think you lose some sterility in pulling from the bag plus our bags are usually preloaded in pumps by RNs. Unlockimg bag from pump would slow process down. Also, those doses seem a little light.

I do like CSEs but this study makes you think a bit.
Click to expand...

The guys at the local OB hospital do on the order of 5000 CSE's per year using this technique without any infection issues, so I have a hard time believing there's any clinically significant sterility breach drawing off the bag.

I agree this technique makes no sense if the bag is already locked in the pump.

Dosing is great. Pts are comfortable before the tape is on and 90% of the time the BP remains essentially unchanged. NRFHT's are few and far between and self limited to a couple mins. Sublingual NTG is great for breaking a tetanic uterine contraction which is usually the culprit.

If I'm not doing a CSE for whatever reason, then I just like to bolus the cath with the remaining lido in the kit (left over test dose 1.5% plus the leftover 1% from skin local)
 
SaltyDog said:
The guys at the local OB hospital do on the order of 5000 CSE's per year using this technique without any infection issues, so I have a hard time believing there's any clinically significant sterility breach drawing off the bag.

I agree this technique makes no sense if the bag is already locked in the pump.

Dosing is great. Pts are comfortable before the tape is on and 90% of the time the BP remains essentially unchanged. NRFHT's are few and far between and self limited to a couple mins. Sublingual NTG is great for breaking a tetanic uterine contraction which is usually the culprit.

If I'm not doing a CSE for whatever reason, then I just like to bolus the cath with the remaining lido in the kit (left over test dose 1.5% plus the leftover 1% from skin local)
Click to expand...

Obviously infections are a very uncommon event and a clinically significant difference would be difficult to measure. Still, something I think worth considering.

As a pure CSE, 2.5cc of 1/8th bupi and 2mcg/cc fentanyl seems light but it seems you are injecting additional solution epidurally through needle at LOR and later once catheter is threaded. Still, sounds like you have great results. Always nice to hear different ways of doing things. Thanks
 
Lurch said:
Always nice to hear different ways of doing things. Thanks
Click to expand...

Agree, that's why I love this site. There's no 1 right way to do anything in anesthesia. I've learned so much from SDN and a lot of what I do everyday I've pulled from the Jedi's that have taken the time to post here over the years.
 
When I do a CSE (rare) I keep it simple. one ml of 0.25% of Bup via the CSF, dilate the Epidural space with saline and then thread the catheter. When I skip the Spinal portion of the procedure I dilate the epidural space with 3-4 mls of saline and 5-6 mls of 0.25% Bupivacaine before threading the catheter. I readily admit the CSE has a faster onset than my Epidural only procedure by about 3-4 minutes. That said, I still prefer not to puncture the dura when it isn't necessary.

Both CSE and Epidural analgesia are acceptable techniques for a laboring patient but I certainly concede that less experienced practitioners may prefer the CSE over Epidural because of the fear of bolus dosing a small amount of local through the epidural needle. The CSE eliminates that concern entirely.

http://www.ncbi.nlm.nih.gov/pubmed/23076897
 
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Depends on patient.....

If they're hurting bad.....
25 mcg of intrathecal fentanyl......epidural catheter.....test dose.......secure ....start infusion

-warn them about itching and put in benadryl order. the benadryl is more mental and probably just lets then sleep and get rest while laboring rather than relieve the itch

If they're like "oh it's bad but not that bad, but I'm still ready" (we get those)
see about minus intrathecal fentanyl......15 cc of bag solution through touey when LOR....catheter...secure....infustion

this works for me. i feel like alot of the CSE/Epidural that lead to sections, I look over the drape and see nuchal cords. No science ....just observational evidence.
 
Twiggidy said:
-warn them about itching and put in benadryl order. the benadryl is more mental and probably just lets then sleep and get rest while laboring rather than relieve the itch
Click to expand...


Benedryl is useless for intrathecal opoid induced itching. Ondansetron works better.
 
scudrunner said:
Benedryl is useless for intrathecal opoid induced itching. Ondansetron works better.
Click to expand...
Actually a recent study showed that zofran was ineffective (Blade, can you pull that one up for me?) at treating pruritis from IT opiates.

I still give it for this reason though. It makes ME feel better if nothing else.
 
Noyac said:
Actually a recent study showed that zofran was ineffective (Blade, can you pull that one up for me?) at treating pruritis from IT opiates.

I still give it for this reason though. It makes ME feel better if nothing else.
Click to expand...

Haven't seen the study. There were several prior that showed benefit. And the process is thought to be mediated via 5-HT receptors, as well as mu (and kappa?) receptors. I know naloxone is effective, and 10-20mg propofol may be useful for the GABA-ergic effect, though I've yet to try it.
 
Twiggidy said:
Depends on patient.....

If they're hurting bad.....
25 mcg of intrathecal fentanyl......epidural catheter.....test dose.......secure ....start infusion

-warn them about itching and put in benadryl order. the benadryl is more mental and probably just lets then sleep and get rest while laboring rather than relieve the itch

If they're like "oh it's bad but not that bad, but I'm still ready" (we get those)
see about minus intrathecal fentanyl......15 cc of bag solution through touey when LOR....catheter...secure....infustion

this works for me. i feel like alot of the CSE/Epidural that lead to sections, I look over the drape and see nuchal cords. No science ....just observational evidence.
Click to expand...

Dude, if you're gonna access the IT space why not throw a little local in there and give them some real relief??

Bottom line is: as long as you put some local and some narc in the epidural and/or IT space you're gonna have a happy pt. The rest is just splitting chinchilla hairs.
 
Int J Obstet Anesth. 2014 Aug;23(3):222-6. doi: 10.1016/j.ijoa.2014.04.007. Epub 2014 May 15.
Prevention versus treatment of intrathecal morphine-induced pruritus with ondansetron.
Kung AT1, Yang X2, Li Y2, Vasudevan A2, Pratt S2, Hess P2.
Author information

Abstract
BACKGROUND:
Intrathecal morphine is used for post-cesarean analgesia, but pruritus is a common side effect. Ondansetron would be an attractive treatment because it prevents nausea, is non-sedative or has no anti-analgesic effect. We undertook a study to assess the efficacy of ondansetron for treatment or prophylaxis of intrathecal morphine-induced pruritus.

METHODS:
Healthy paturients undergoing cesarean delivery with intrathecal morphine 250μg and fentanyl 25μg were randomized to receive: prophylaxis (ondansetron 8mg at cord clamping, normal saline 4mL for treatment of pruritus in the post-anaesthesia care unit); treatment (normal saline 4mL at cord clamping, ondansetron 8mg as required in the post-anesthesia care unit) or control (normal saline 4mL in both). Visual analogue scale scores for pruritus, nausea and pain were recorded preoperatively, on arrival to, at 30, 60, and 120min and on discharge from the post-anesthesia care unit. The primary outcome was the peak pruritus score. ANOVA with Bonferroni correction or Fisher's exact test were used to analyze data; P<0.05 was considered significant.

RESULTS:
The study was terminated early when interim analysis indicated no effect. Eighty-two of the intended 180 paturients completed the protocol (26 in control group, 32 in treatment group and 24 in prophylaxis). There were no differences in the rate or severity of pruritus at any assessment point, or the request for treatment. Pruritus was reduced after administration of treatment syringe.

CONCLUSION:
Prophylactic ondansetron did not reduce pruritus when compared with placebo. The use of ondansetron as a treatment did not decrease the severity of pruritus when compared with placebo.
 
Acta Anaesthesiol Scand. 2006 Feb;50(2):239-44.
Ondansetron and tropisetron do not prevent intraspinal morphine- and fentanyl-induced pruritus in elective cesarean delivery.
Sarvela PJ1, Halonen PM, Soikkeli AI, Kainu JP, Korttila KT.
Author information

Abstract
BACKGROUND:
Although intraspinal morphine has been shown to be effective in providing analgesia after cesarean delivery, pruritus as a side-effect remains a common cause of dissatisfaction. The role of ondansetron has been studied in preventing pruritus but the results have been contradictory.

METHODS:
We randomized 98 parturients undergoing elective cesarean section using combined spinal-epidural anesthesia into a double-blinded trial to receive tropisetron 5 mg (T group) or ondansetron 8 mg (O group) or placebo (NaCl group) after delivery, when intrathecal morphine 160 microg and fentanyl 15 microg were used for post-operative pain control. The patients additionally received ketoprofen 300 mg per day. Post-operative itching, nausea and vomiting, sedation and need for rescue analgesics were registered every 3 h up to 24 h, and all patients were interviewed on the first post-operative day.

RESULTS:
Seventy-six percent of the parturients in the placebo group, 87% in the ondansetron, and 79% in the tropisetron group had itching. The incidence of post-operative nausea and vomiting was 21%, 20% and 11% of the patients in the placebo, ondansetron and tropisetron groups, respectively. Medication for pruritus was needed by 31%, 23% and 39% of the patients in the placebo, ondansetron and tropisetron groups, respectively. In the post-operative questionnaire, the patients reported less post-operative nausea in the tropisetron group than in the placebo group (P < 0.01).

CONCLUSION:
Neither ondansetron nor tropisetron prevent itching caused by intrathecal morphine with fentanyl. However, tropisetron reduced post-operative nausea.
 
SaltyDog said:
Dude, if you're gonna access the IT space why not throw a little local in there and give them some real relief??

Bottom line is: as long as you put some local and some narc in the epidural and/or IT space you're gonna have a happy pt. The rest is just splitting chinchilla hairs.
Click to expand...

Seriously, I can't tell you why. One day as a resident, my attending who covered the OB floor at one of our two hospitals told me to try some IT fentanyl 25mcg and watch how their pain is immediately relieved. So i guess I'm saying I don't add anything extra because what I already give works. I'm sure your method works too.
 
Twiggidy said:
Seriously, I can't tell you why. One day as a resident, my attending who covered the OB floor at one of our two hospitals told me to try some IT fentanyl 25mcg and watch how their pain is immediately relieved. So i guess I'm saying I don't add anything extra because what I already give works. I'm sure your method works too.
Click to expand...

I've used the IT fentanyl technique you described. The small advantage it may have over CSE is that you can be more assured that your epidural catheter is not intrathecal. I have found it useful when I have a particularly squirrely patient that still has several centimeters worth of dilation remaining. Also, it seems to keep expectations more reasonable as the parturient doesn't experience the relative bliss of a spinal anesthesia followed by the less bliss epidural analgesia.


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GABAergic said:
I've used the IT fentanyl technique you described. The small advantage it may have over CSE is that you can be more assured that your epidural catheter is not intrathecal. I have found it useful when I have a particularly squirrely patient that still has several centimeters worth of dilation remaining. Also, it seems to keep expectations more reasonable as the parturient doesn't experience the relative bliss of a spinal anesthesia followed by the less bliss epidural analgesia.


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Click to expand...

That's why I just do an Epidural with about 8mls of 0.25% Bup plus 100 ug Fentanyl. Pain relief is excellent and takes about 3 minutes longer vs a CSE technique in my hands. I then follow up with the usual dilute Bup with Fentanyl from the bag. Does anyone really think an extra 3 minutes of discomfort/pain during labor makes a difference in the overall experience?
Again, if you are comfortable with your CSE technique then continue it; or, if you are still getting to that N=300-400 for labor epidurals then keep doing whatever makes you feel most comfortable.
 
GABAergic said:
I've used the IT fentanyl technique you described. The small advantage it may have over CSE is that you can be more assured that your epidural catheter is not intrathecal. I have found it useful when I have a particularly squirrely patient that still has several centimeters worth of dilation remaining. Also, it seems to keep expectations more reasonable as the parturient doesn't experience the relative bliss of a spinal anesthesia followed by the less bliss epidural analgesia.


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Click to expand...

This. I'm by no means an epidural expert, and I've done a handful of CSE's... but the patients think their epidural is not working when the spinal wears down. I kept getting called about this patient who was literally a demon before the CSE. She rolled on the ground off her medicine ball, looked at me with hell hound eyes and screamed "WHY CAN'T YOU JUST TAKE THE PAIN AWAY." (To be fair, she had cervidil and was hypercontracting when they called me).

Tried increasing her basal rate and bolusing her with the premade epidural solution... still too much pain for her.

My attending finally told me to load her up with Lidocaine 1% 10cc, and fentanyl 50 mcg right into her epidural. Settled her right down. Delivered no problems.

I think that CSEs are fantastic in the short term for the patient, the nurse, and you even. But, later on maybe not so much.
 
CodeBlu said:
This. I'm by no means an epidural expert, and I've done a handful of CSE's... but the patients think their epidural is not working when the spinal wears down. I kept getting called about this patient who was literally a demon before the CSE. She rolled on the ground off her medicine ball, looked at me with hell hound eyes and screamed "WHY CAN'T YOU JUST TAKE THE PAIN AWAY." (To be fair, she had cervidil and was hypercontracting when they called me).

Tried increasing her basal rate and bolusing her with the premade epidural solution... still too much pain for her.

My attending finally told me to load her up with Lidocaine 1% 10cc, and fentanyl 50 mcg right into her epidural. Settled her right down. Delivered no problems.

I think that CSEs are fantastic in the short term for the patient, the nurse, and you even. But, later on maybe not so much.
Click to expand...

8 mL 0.25% bup and 100 mcg fent works well in this situation, and lasts a bit longer.

I am a narcotics only in CSE guy, unless they are clearly delivering in the next hour.


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pjl said:
8 mL 0.25% bup and 100 mcg fent works well in this situation, and lasts a bit longer.

I am a narcotics only in CSE guy, unless they are clearly delivering in the next hour.

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Click to expand...

What do you usually give in your spinal for a CSE then? Fentanyl?
 
CodeBlu said:
This. I'm by no means an epidural expert, and I've done a handful of CSE's... but the patients think their epidural is not working when the spinal wears down. I kept getting called about this patient who was literally a demon before the CSE. She rolled on the ground off her medicine ball, looked at me with hell hound eyes and screamed "WHY CAN'T YOU JUST TAKE THE PAIN AWAY." (To be fair, she had cervidil and was hypercontracting when they called me).

Tried increasing her basal rate and bolusing her with the premade epidural solution... still too much pain for her.

My attending finally told me to load her up with Lidocaine 1% 10cc, and fentanyl 50 mcg right into her epidural. Settled her right down. Delivered no problems.

I think that CSEs are fantastic in the short term for the patient, the nurse, and you even. But, later on maybe not so much.
Click to expand...

The key (and this applies to pretty much everything in life) is to manage expectations. Part of my spiel is telling the pts "You're going to be extra numb for the first 60-90 mins. Use that time to take a nap since it'll be the last one you get for a couple years. After that the epidural is perfect when you can tell you're having a contraction, but it isn't painful. You don't want to be totally numb because that makes it very difficult to push when the time comes."

My experience, and there is pretty good supporting evidence in the literature, is that CSE pts require less boluses/top off's than pts receiving straight epidurals.

Residents: Play around with as many different techniques as possible. There's no right way - just the way that works best for you.
 
Have you tried "Well the Virgin Mary didn't technically know who the father was either, but she did it without an epidural"

Try that line next time and see how it goes...
 
sigrhoillusion said:
Have you tried "Well the Virgin Mary didn't technically know who the father was either, but she did it without an epidural"

Try that line next time and see how it goes...
Click to expand...

In residency we had an attending who, anytime he went in for an epidural on a teenage pt would walk in the room, see the father standing off in the corner, and ask the pt "So, where did you two meet? Church??"

They would always just say "No, at school."

I always had to fight the urge to laugh, but the kids never even realized he was bustin' on 'em.
 
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