Practices doing both CSE and Epidurals for labor

[agammaglobulin]

If you have some attendings doing epidurals and some doing CSE's for laboring patients, do you have 2 seperate Epidural trays (i.e. CSE and Epidural trays)? Or do you just have one tray and add on/subtract additional equipment? The Tuohy angle seems too acute in the epidural tray in my practice to add in a spinal needle without risk of the needle bending so am wondering what others do.

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[deleted162650]

Same kit. Just drop a 25g x 120mm pencil point needle in the tray. Works perfect. Haven't seen a bent needle yet and I've doing it this same way for 4 years. I've actually never even opened up a "proper" CSE tray.

 

[facted]

Same as SaltyDog. Can easily use the epi kit and just add a spinal needle (have done that with many different kits without issue). With that being said, I know the HA risk in the literature is no different than standard epi but I've personally seen quite a few HA's from my partners CSE's in the last few weeks (I don't really do CSE's). We use a 25g pencil point needle for the spinal. Personally don't think the CSE is worth it in my opinion but obviously depends on the situation.

 

[soorg]

Not a fan of CSEs at all. I don't care what any "literature" says - they cause fetal bradycardia. Not worth the risk. A regular epi and you have relief within 15 minutes, max.

 

[facted]

Not a fan of CSEs at all. I don't care what any "literature" says - they cause fetal bradycardia. Not worth the risk. A regular epi and you have relief within 15 minutes, max.

I'm with this 100%.

 

[rakotomazoto]

I have used the CSE kits at a community hospital we rotate through, the group there uses CSE's as their default plan so we get to do a lot of them and see the pro's and con's. The box is bigger, there is an extra syringe and needle for drawing up meds, probably costs more since there is more stuff in it. Overall, very similar to standard epidural tray. When I was there, the kit did not have any local anesthetics (they said it was a temporary issue with their manufacturer), so they had us squirt out what we would need, 5-6ml, from a 20ml vial of 0.5% bupivicaine. Draw up your spinal dose first, then use the remainder for skin infiltration/local. It was very different than how our academic attendings do it, but seemed to work well enough. Patients and nurses loved it and during 6 weeks there, I never did a crash due to decels after spinal. Maybe their OB group has a higher risk tolerance?

It's nice to have it all in one box, but totally unnecessary. I have never had issues with just dropping in a spinal needle to the standard epidural kit at my home institution.

 

[pgg]

You can just drop a spinal needle on the epidural kit, works fine.

We also have a CSE kit with just a spinal needle and Tuohy with the extra hole so the spinal needle can go straight through. I liked this add-on kit better, for admittedly trivial subjective reasons. The Tuohy in the CSE kit is not as sharp as the one in our epidural kits (made by Arrow). I think it gives better tactile feedback for LOR. Same issue with using that Tuohy with the spinal needle - better feel when puncturing the dura without having to slide the spinal needle tip up the curve in the Tuohy. And I suspect the duller Tuohy may cause fewer unnoticed wet taps just by gently touching the dura during even a well-performed epidural.


As for the literature that says there's no PDPH difference for a CSE vs straight epidural ... I think it says that because the literature is written by people at academic hospitals, and the subjects in their studies are getting the procedures performed by learners, often very junior residents.

In the hands of a newbie, the CSE technique definitely lowers the risk of PDPH. Newbies get a lot of uncertain LORs, because they're off midline, or never really engaged with the ligament, and they don't know what they're feeling. When they do a CSE, the spinal needle is a good feel-ahead tool. Get a LOR? Put in the spinal needle. Yes CSF - good, dose it and thread the catheter. No CSF - you can surely safely advance the Tuohy some more. Result: the reduction in 17 g Tuohy wet taps more than overcomes the (probably) increased PDPH rate with giving everyone a 25 or 27 g dural puncture.

In the hand of an experienced person who doesn't need the CSE feel-ahead crutch, whose wet-tap and PDPH rate is already super low (in the <1% range) ... that's not likely to be true. But experienced people aren't producing the Ns in the academic studies.

I'm sure there's a higher absolute incidence of PDPHs amongst my patients who all get CSEs, and others' patients who always get straight epidurals. But I still do CSEs because
1) not all PDPHs are created equal; the headache from a 25 or 27 g hole is just not as bad, as persistent, or as likely to re-present for an EBP as a 17 g hole
2) I personally feel the analgesic, time, and safety benefits outweigh the risk
3) fetal bradycardia, if it happens, is easily treated (and not with a stat c-section)

 

[Twiggidy]

Not a fan of CSEs at all. I don't care what any "literature" says - they cause fetal bradycardia. Not worth the risk. A regular epi and you have relief within 15 minutes, max.

Whoa....slow down tiger. For a patient in pain they can definitely be worth it. If a G1 is 8-10 cm and in hellish pain, 25 mcg of intrathecal fentanyl (maybe even less) will have her ready to dump hubby and marry you. Do i routinely do it?? no....but if i want a lady to happy fast so she thinks I'm the best thing since sliced bread, you better believe that spinal needle is coming

 

[leaverus]

Same kit. Just drop a 25g x 120mm pencil point needle in the tray. Works perfect. Haven't seen a bent needle yet and I've doing it this same way for 4 years. I've actually never even opened up a "proper" CSE tray.

I believe you mean 27G? i'm not aware of any 25G needles long enough to extend past a standard tuohy. either way not sure what you guys mean by bent needle; the 27G needle does bend a bit when it exits the tip of tuohy but what does that matter?

Whoa....slow down tiger. For a patient in pain they can definitely be worth it. If a G1 is 8-10 cm and in hellish pain, 25 mcg of intrathecal fentanyl (maybe even less) will have her ready to dump hubby and marry you. Do i routinely do it?? no....but if i want a lady to happy fast so she thinks I'm the best thing since sliced bread, you better believe that spinal needle is coming

agree. I occasionally do CSE for multips who are gonna go fast; anecdotally haven't seen any increase in fetal bradycardia. but I give her straight up local; i'd waste too much time letting her writhe in pain if I had to go check out narc from the pyxis every time.

 

[anbuitachi]

I like DPEs. CSEs cause way too much itching for the slightly faster onset.

 

[sleepallday]

I guess I'm the only one that agrees with the OP. When I add a spinal needle to the epidural kit, it feels like the spinal needle catches at the end of the Touhy. But we actually have a separate spinal/touhy packet that i just drop in the epidural kit and use that.

 

[Twiggidy]

I like DPEs. CSEs cause way too much itching for the slightly faster onset.

Yeah. i just tell them, "hey. you may feel itchy but it's better than pain" and most agree. then i offer them benadryl, which i don't think helps the itch, calms them and then once the epidural level reaches they dont itch anymore (similar to giving fentanyl for C/S. the never itch)

 

[deleted162650]

Give less narc in the IT dose. I've never had someone complain or even comment that they itched. 2.5mL of the 1/8th Bupi +fent 2/mL bag solution and you're golden.

 

[anbuitachi]

I do 25 mcg for cse

Give less narc in the IT dose. I've never had someone complain or even comment that they itched. 2.5mL of the 1/8th Bupi +fent 2/mL bag solution and you're golden.

 

[deleted162650]

I believe you mean 27G? i'm not aware of any 25G needles long enough to extend past a standard tuohy.

Well prepare to have your mind blown

I would be happy to use 27's, but we don't stock any 27g needles.

 

[narcusprince]

In experienced hands just bolus through the darn epidural needle. My patients are happy 5 minutes with 5cc of 0.2% ropi. Then bolus 10 cc through epidural catheter after the test dose. Done.....

 

[Noyac]

We have two different trays.

CSE's don't cause PDPH's any more than epidurals. Mostly because neither one actually causes a headache. It's the wet tap from a touhy that causes it. I've been doing CSE's for 14 yrs and I can only recall one fetal Brady post placement but I don't recall if it was a CSE or epidural honestly. But it resolved with ephedrine just fine. I believe it is the dose that matters. Also, I see some say that these pts don't need a bolus. That's not my experience. I think they all need one.

15 min is too long for me to wait for them to get comfy. I like instant gratification. Which btw is achieveable with a straight epidural as well. Just dose through the needle. It's almost instant.

I think everyone has "their" approach and thinks that their approach is the best or else they wouldn't do it that way. But if you ask the nurses they know who's approach works best for them. And they are usually happy to tell you. Just ask them.

 

[Arch Guillotti]

In experienced hands just bolus through the darn epidural needle. My patients are happy 5 minutes with 5cc of 0.2% ropi. Then bolus 10 cc through epidural catheter after the test dose. Done.....

If they are happy why are you giving an additional 10 cc of local?

 

[narcusprince]

If they are happy why are you giving an additional 10 cc of local?

The 5cc is not enough to get them fully comfortable. It is enough to bring the pain from a 10 to a 7 the rest brings it down to a 4-5. Also the 5cc may dilate the space and decrease the incidence of unilateral block.

 

[Noyac]

The 5cc is not enough to get them fully comfortable. It is enough to bring the pain from a 10 to a 7 the rest brings it down to a 4-5. Also the 5cc may dilate the space and decrease the incidence of unilateral block.

I give at least 10cc through the touhy if not the full dose. If they are not completely comfy after 10cc and threading the catheter and securing it then I will give another 5cc through the catheter.
I like your reasoning concerning dilating the space so the catheter passes easier and lessens the risk of unilateral block. I do that with the NS in the kit even when I do a CSE. OR any other epidural I place.

 

[deleted697535]

Loss of resistance to ropivicaine lol

 

[deleted162650]

Loss of resistance to ropivicaine lol

Don't laugh. I use 1/8th bupi + fent 2/mL for my LOR fluid.

 

[narcusprince]

The viscosity of the fluid is stickier. This can cause the lor syringe to stick and may result in inadvertent dural puncture.

 

[Noyac]

The viscosity of the fluid is stickier. This can cause the lor syringe to stick and may result in inadvertent dural puncture.

Are you certain about that?

 

[narcusprince]

I know the fluid is sticky. I tried it a few times got a good lor but it felt less smooth.

 

[deleted162650]

The viscosity of the fluid is stickier. This can cause the lor syringe to stick and may result in inadvertent dural puncture.

I always have a little air bubble in the LOR syringe for that nice bump & squish. It doesn't ever stick this way.

I highly doubt there's a viscosity difference that can be detected by humans. I'll make it a note not to use albumin for LOR fluid though.

 

[deleted50478]

In experienced hands just bolus through the darn epidural needle. My patients are happy 5 minutes with 5cc of 0.2% ropi. Then bolus 10 cc through epidural catheter after the test dose. Done.....

Or better yet just bolus all 15 through the epidural needle and skip the test dose. Your patient will be comfortable before the other guy has finished taking out the narcotics for their quick onset fentanyl cse's.

 

[leaverus]

We have two different trays.


15 min is too long for me to wait for them to get comfy. I like instant gratification. Which btw is achieveable with a straight epidural as well. Just dose through the needle. It's almost instant.

.

i agree and like to get her comfy as fast as possible but i dont know how you're getting "almost instant" pain relief. i always dose 10-15cc 0.25% bup through the tuohy and sometimes it takes up to 15-20min for the pt to feel better; long enough that it doesn't seem any faster than giving through the catheter. it doesn't sound like i'm doing anything differently from you.

 

[Noyac]

i agree and like to get her comfy as fast as possible but i dont know how you're getting "almost instant" pain relief. i always dose 10-15cc 0.25% bup through the tuohy and sometimes it takes up to 15-20min for the pt to feel better; long enough that it doesn't seem any faster than giving through the catheter. it doesn't sound like i'm doing anything differently from you.

No fentanyl? Maybe that's the difference.

 

[deleted162650]

If you want them comfy ASAP and don't like CSE's then just load them with all the lido that comes in the kit. Give them the full 5cc test dose + the leftover 2-3mLs of 1% from the skin local. Dilute bupi just isn't gonna set up that fast no matter how much you give. Fent definitely helps as well.

 

[deleted697535]

Someone told me there's a study that shows no difference in pain score btwn cse and standard epidural at 15 mins.

Never looked it up. Anyone ever see that?

 

[leaverus]

No fentanyl? Maybe that's the difference.

fentanyl? forget it, that's too much work.

Someone told me there's a study that shows no difference in pain score btwn cse and standard epidural at 15 mins.

Never looked it up. Anyone ever see that?

you can quote me all the studies you want; every single one of my pts i've ever done a cse on will disagree with you.

 

[Noyac]

If you want them comfy ASAP and don't like CSE's then just load them with all the lido that comes in the kit. Give them the full 5cc test dose + the leftover 2-3mLs of 1% from the skin local. Dilute bupi just isn't gonna set up that fast no matter how much you give. Fent definitely helps as well.

The more you post, the more I begin to think we were trained at the same place.

 

[pgg]

Someone told me there's a study that shows no difference in pain score btwn cse and standard epidural at 15 mins.

Never looked it up. Anyone ever see that?

There's a study to show everything, but I don't believe this allegedly-existent one.

Anyone whose ever done more than five spinals for labor knows they are profoundly better than epidurals for the first hour or so ... to the point that one reason some people don't like CSEs, is because they don't like getting called 90 minutes later when the patient perceives that the (normal, functioning, well placed) epidural isn't working right. Because the low dose local + opiate intrathecal dose is that good.

Also, epidurals that are accompanied by a dural puncture (whether a CSE or just a DPE) are possibly superior to straight epidurals, in terms of absolute pain scale and less sacral sparing. I have some issues with the DPE study done at B&W showing how awesome they are, but there's probably some truth to it.

In any case, the CSE is unquestionably better for the first 10-15 minutes. We're not doing them because they're "roughly equivalent" to straight epidurals after 15 or 30 minutes.

Patients love them. They're faster (thread catheter, skip test dose, hit start on pump, leave). I won't be so bold as to claim they're safer (no data to prove it), but I think a procedure that involves bolusing 10+ mL, either via Tuohy or catheter, carries inherently more risk than one that involves bolusing a fraction of a mL followed by starting a slow infusion.

 

[narcusprince]

Pgg,
The next level of my thinking is bp decreases with CSEs. With my straight epidural mom gets comfortable fast moms bp stays normal and I rarely have to give vasopressors. Its a fine technique.

 

[pgg]

Intrathecal analgesic doses don't cause hypotension. I never have to treat BP. I literally hit start on the pump and walk out.

I'm not saying your way is wrong. Just that mine is better.

Obviously we all think our way is the best way else we wouldn't do it our way.

 

[deleted162650]

The more you post, the more I begin to think we were trained at the same place.

I'm almost positive we didn't, but you know what they say about great minds . . .

 

[BLADEMDA]

Intrathecal analgesic doses don't cause hypotension. I never have to treat BP. I literally hit start on the pump and walk out.

I'm not saying your way is wrong. Just that mine is better.

Obviously we all think our way is the best way else we wouldn't do it our way.

Both techniques have their pluses and minuses. I do agree that the set up is a bit faster with a dural puncture followed by an Epidural. But, since this is a labor epidural I am not enthusiastic about puncturing the dura when it isn't necessary. We do agree that the laboring mom gets used to the heavier, denser block of the CSE vs a standard labor epidural which may increase phone calls for more local anesthetic.

Both techniques meet the standard of care and if you are reluctant to bolus any local through the epidural space then the CSE may indeed be the better technique. For those of us used to putting some local through the space the onset is pretty quick (or quick enough) with good patient satisfaction.

 

[deleted162650]

Both techniques have their pluses and minuses. I do agree that the set up is a bit faster with a dural puncture followed by an Epidural. But, since this is a labor epidural I am not enthusiastic about puncturing the dura when it isn't necessary. We do agree that the laboring mom gets used to the heavier, denser block of the CSE vs a standard labor epidural which may increase phone calls for more local anesthetic.

That's been the opposite of my experience. I get significantly fewer calls for bolus requests on CSE pts than on those with straight CLE's.

I'll also go on record as saying that I think DPE's are stupid. If you're gonna access the IT space then for God's sake put some drug in there. I've never been a fan of just pulling out

This whole discussion reminds me of this:

 

[Noyac]

Anyone whose ever done more than five spinals for labor knows they are profoundly better than epidurals for the first hour or so ... to the point that one reason some people don't like CSEs, is because they don't like getting called 90 minutes later when the patient perceives that the (normal, functioning, well placed) epidural isn't working right. Because the low dose local + opiate intrathecal dose is that good.

Also, epidurals that are accompanied by a dural puncture (whether a CSE or just a DPE) are possibly superior to straight epidurals, in terms of absolute pain scale and less sacral sparing. I have some issues with the DPE study done at B&W showing how awesome they are, but there's probably some truth to it.

In any case, the CSE is unquestionably better for the first 10-15 minutes. We're not doing them because they're "roughly equivalent" to straight epidurals after 15 or 30 minutes.

Patients love them. They're faster (thread catheter, skip test dose, hit start on pump, leave). I won't be so bold as to claim they're safer (no data to prove it), but I think a procedure that involves bolusing 10+ mL, either via Tuohy or catheter, carries inherently more risk than one that involves bolusing a fraction of a mL followed by starting a slow infusion.

Wait a second. We are all physicians here. We have more than one way to skin a cat, unlike our nursing counterparts. We tailor our anesthetic to the pt. Again, unlike our nursing counterparts. We have more than one tool in our tool box, unlike our nursing counterparts.
So, use these two techniques in an intelligent manner. For example, I will place a CSE in a multip beyond 4 cm all day long. By the time the initial spinal dose states to wane they are pushing and they think it's the best **** ever. You give me a primip less than 6cm writhing in pain and I'm placing a slow epidural. She is gonna wonder if the thing is even working for the first 20 min. But once she realizes it's working then she doesn't expect miracles. Now the tricky part is those in between pts. Use good judgement.

 

[leaverus]

I like DPEs. CSEs cause way too much itching for the slightly faster onset.

what size needle are you using for the dural puncture?

That's been the opposite of my experience. I get significantly fewer calls for bolus requests on CSE pts than on those with straight CLE's.

I'll also go on record as saying that I think DPE's are stupid. If you're gonna access the IT space then for God's sake put some drug in there. I've never been a fan of just pulling out

View attachment 223399

i kinda agree with you; never done DPE but it seems wrong somehow to make a dural puncture and not inject medication. on the other hand, i thought the theory of DPE is that you ARE getting medication into the intrathecal space - at least by entrainment if not by direct injection. in any case, i'm always for trying new techniques to add to my repertoire so i'm gonna start doing some to compare for myself.

 

[anbuitachi]

what size needle are you using for the dural puncture?



i kinda agree with you; never done DPE but it seems wrong somehow to make a dural puncture and not inject medication. on the other hand, i thought the theory of DPE is that you ARE getting medication into the intrathecal space - at least by entrainment if not by direct injection. in any case, i'm always for trying new techniques to add to my repertoire so i'm gonna start doing some to compare for myself.

27G

 

[leaverus]

27G

i thought past study(ies) showed 27G probably makes too small a hole to make much difference? what's been your experience in comparison to CSE and CLE?

 

[Hoya11]

There's a study to show everything, but I don't believe this allegedly-existent one.

Anyone whose ever done more than five spinals for labor knows they are profoundly better than epidurals for the first hour or so ... to the point that one reason some people don't like CSEs, is because they don't like getting called 90 minutes later when the patient perceives that the (normal, functioning, well placed) epidural isn't working right. Because the low dose local + opiate intrathecal dose is that good.

Also, epidurals that are accompanied by a dural puncture (whether a CSE or just a DPE) are possibly superior to straight epidurals, in terms of absolute pain scale and less sacral sparing. I have some issues with the DPE study done at B&W showing how awesome they are, but there's probably some truth to it.

In any case, the CSE is unquestionably better for the first 10-15 minutes. We're not doing them because they're "roughly equivalent" to straight epidurals after 15 or 30 minutes.

Patients love them. They're faster (thread catheter, skip test dose, hit start on pump, leave). I won't be so bold as to claim they're safer (no data to prove it), but I think a procedure that involves bolusing 10+ mL, either via Tuohy or catheter, carries inherently more risk than one that involves bolusing a fraction of a mL followed by starting a slow infusion.

In some ways this is like the surgeon who complains about a 10 minute delay and then goes on to take 4.5hrs to do a hernia...

Labor and contractions have been happening for hours (sometimes days).

There are so many other factors that are at play to determine the time that the contraction pain stops and mom gets comfy.... at what point do they go to the hospital, how long does check in take, now we start the iv and give a bolus, hold on the nurses are changing shift, hold on i have to go to the bathroom, etc...

so why am i going to go above and beyond ( and more importantly arguably add a level of risk ) for a possible 2-5 minute difference (which is like 1-2 contractions)? im not even going to dose through the needle... i do it the way i always do it and dont let the hysterics of the others throw me off and lead me to a complication...needle gets placed, catheter goes in, test dose, bolus 2% lido with epi.

The only time that I have done DPE was as a resident, and while i agree that it doesnt make sense to puncture the dura and then not give anything, i was taught that the purpose of the puncture is to confirm proper epidural positioning if a possible false loss of resistance should occur during a difficult placement. meaning that if you can puncture the dura through the tuohy then you are in the right place with your tuohy , which again is an assumption

 

[BLADEMDA]

i thought past study(ies) showed 27G probably makes too small a hole to make much difference? what's been your experience in comparison to CSE and CLE?

A randomized trial of dural puncture epidural technique compared with the standard epidural technique for labor analgesia. - PubMed - NCBI (25 G non cutting needle)

Dural puncture with a 27-gauge Whitacre needle as part of a combined spinal-epidural technique does not improve labor epidural catheter function. - PubMed - NCBI (27 G non cutting needle)

Dural Puncture Epidural Technique Improves Labor Analgesia... : Anesthesia & Analgesia

 

[BLADEMDA]

First, the notable CSE transition from initial spinal analgesia to ongoing epidural analgesia often provokes a request for physician top-up interventions. Although our findings are underpowered to robustly evaluate this outcome, we observed earlier requests for top-up interventions with the CSE technique. Second, when administered in early labor, CSE analgesia has been associated with greater uterine contractility and more rapid cervical dilation23,24; these alterations could contribute to greater analgesia requirements and fetal consequences.

In summary, analgesia onset was most rapid with the CSE technique, with no difference between the DPE and EPL techniques; however, the DPE technique has fewer maternal and fetal side effects compared with the CSE technique, and improved block quality when compared with the EPL technique. We conclude that the DPE appears to offer a favorable risk-benefit ratio for initiating and maintaining analgesia in laboring parturients

Dural Puncture Epidural Technique Improves Labor Analgesia... : Anesthesia & Analgesia

 

[BLADEMDA]

http://journals.lww.com/anesthesia-...=2017&issue=02000&article=00001&type=Fulltext

 

[deleted697535]

In some ways this is like the surgeon who complains about a 10 minute delay and then goes on to take 4.5hrs to do a hernia...

Labor and contractions have been happening for hours (sometimes days).

There are so many other factors that are at play to determine the time that the contraction pain stops and mom gets comfy.... at what point do they go to the hospital, how long does check in take, now we start the iv and give a bolus, hold on the nurses are changing shift, hold on i have to go to the bathroom, etc...

so why am i going to go above and beyond ( and more importantly arguably add a level of risk ) for a possible 2-5 minute difference (which is like 1-2 contractions)? im not even going to dose through the needle... i do it the way i always do it and dont let the hysterics of the others throw me off and lead me to a complication...needle gets placed, catheter goes in, test dose, bolus 2% lido with epi.

The only time that I have done DPE was as a resident, and while i agree that it doesnt make sense to puncture the dura and then not give anything, i was taught that the purpose of the puncture is to confirm proper epidural positioning if a possible false loss of resistance should occur during a difficult placement. meaning that if you can puncture the dura through the tuohy then you are in the right place with your tuohy , which again is an assumption

I like this way of thinking. Surgeons get an OR an anesthetist and 3 nurses to drain an abscess. Like that is literally thousands of dollars to pop a big zit.

We tube and line asa5s in the corner of a dark room in emerg or some other sh1t hole with 1 nurse that may or may not help.

Sorry that's an off topic comparison but really the woman is having a freaking baby. Surely she expects and can tolerate 15 mins more of pain!?!

Personally I feel the benefit for cse on the labour floor does not outweigh the risks, so I don't do it.

You know I don't even give lido anymore as my test dose. 0.1 ropi with fent, 20 mls. Test and load. And the women still seem comfortable as I'm leaving the ward after my documentation. Like 16 to 18 mins after coming in...

I do all my epidurals left lateral so it doesn't matter to me how much they move. And also lor to saline so very few patchy blocks now too...

I like the idea of a cse but I'd only do it if the monitoring was better and nurses were happy running phenyl for the odd case

 

[deleted697535]

During the first stage of labor, the typical pain score was 1.4 for women receiving CSE versus 1.9 for those receiving standard epidural analgesia. This 0.5-point difference was statistically significant. Women in the CSE group also had a shorter time to complete pain control -- an average of 11 minutes faster than the epidural group.


https://www.sciencedaily.com/releases/2013/02/130227121618

 

[BLADEMDA]