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Year : 2011  |  Volume : 55  |  Issue : 4  |  Page : 430-431  

Sequential combined spinal epidural block

Department of Anaesthesiology & Critical Care, University College of Medical Sciences & GTB Hospital, Delhi, India

Date of Web Publication13-Sep-2011

Correspondence Address:
Asha Tyagi
103, Siddhartha Enclave, New Delhi - 14
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5049.84833

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How to cite this article:
Tyagi A, Kumar S, Salhotra R. Sequential combined spinal epidural block. Indian J Anaesth 2011;55:430-1

How to cite this URL:
Tyagi A, Kumar S, Salhotra R. Sequential combined spinal epidural block. Indian J Anaesth [serial online] 2011 [cited 2021 Aug 5];55:430-1. Available from: https://www.ijaweb.org/text.asp?2011/55/4/430/84833


We would like to congratulate Dr. Pandya for his timely review on recent advancements in the field of labor analgesia. The newer refinements and developments in the field of central neuraxial blockade are indeed "exciting" as pointed out by the author. [1] However, we wish to differ from the author regarding the concept of "sequential" combined spinal epidural (CSE) block as a technique, whether used for labor analgesia or as an anaesthetic technique.

The author states that a CSE is a "sequential" "needle through needle" technique that utilizes the advantage of a rapid and profound intrathecal block along with the flexibility and longer duration of an epidural block. It appears from these statements that the "sequential" nature of the block is deemed to be due to the sequence of the initial intrathecal injection followed by the epidural one. However, a sequential CSE is a refinement and advancement of the CSE, whether used as needle through needle or separate injections. It does not merely refer to the sequence of intrathecal and epidural injections one after the other. It implies the deliberate intrathecal injection of a dose of local anaesthetic that is inadequate for the planned surgery. It is then supplemented with small volumes of epidural injections, aiming to achieve the desired block level. [2],[3] This intentional intrathecal underdosing followed by smaller than usual epidural injectate volumes has been shown to be of utility in several patients with compromised cardiorespiratory condition, helping to maintain cardiovascular stability. [4] How the small volumes of epidurally injected local anaesthetic help in augmenting the inadequate spinal block, have been a matter of several observations and trials. The epidurally injected small volumes result in augmenting the spinal block to a larger extent than expected with usage of plain epidural, by causing a thecal compression, [5] as well as by converting pre-existing areas of subclinical analgesia to complete analgesia. [6]

   References Top

1.Pandya ST. Labour analgesia: Recent advances. Indian J Anaesth 2010;54:400-8.  Back to cited text no. 1
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2.McNaught AF, Stocks GM. Epidural volume extension and low-dose sequential combined spinal-epidural blockade: Two ways to reduce spinal dose requirement for caesarean section. Int J Obstet Anesth 2007;16:346-53.  Back to cited text no. 2
3.Bray JK, Fernando R, Patel NP, Columb MO. Suprasternal Doppler estimation of cardiac output: Standard versus sequential combined spinal epidural anesthesia for cesarean delivery. Anesth Analg 2006;103:959-64.  Back to cited text no. 3
4.Hamlyn EL, Douglass CA, Plaat F, Crowhurst JA, Stocks GM. Low-dose sequential combined spinal-epidural: An anaesthetic technique for caesarean section in patients with significant cardiac disease. Int J Obstet Anesth 2005;14:355-61.  Back to cited text no. 4
5.Blumgart CH, Ryall D, Dennison B, Thompson-Hill LM. Mechanism of extension of spinal anaesthesia by extradural injection of local anaesthetic. Br J Anaesth 1992;69:457-60.  Back to cited text no. 5
6.Leeda M, Stienstra R, Arbous MS, Verschure MJ, Dahan A, Veering BT, et al. The epidural "top-up": Predictors of increase of sensory blockade. Anesthesiology 2002;96:1310-4.  Back to cited text no. 6


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