Journal Reading

Combined spinal-epidural technique:

single-space vs double distant space
technique
dr. Muh. Kemal Putra

Pembimbing :
Dr. dr. Christrijogo Sp.An, KAR

Departemen Anestesiologi dan Reanimasi

RSUD Dr. Soetomo-FK Universitas Airlangga
Surabaya
2018
Background

 Combined spinal-epidural-general anesthesia (CSE-GA) offers several

advantages over general anesthesia alone.

 In CSE,several technical improvements have been proposed as

attempts to improve the technique, and reduce the incidence of
complication.

Slavkovi Z, et al. Combined spinal-epidural technique: single-space vs double distant space technique.
Vojnosanit Pregl 2013; 70(10): 953–8.
Single space “needle-through-needle” technique (SST)

 Performed using a modified Touhy needle that has a

back eye. An epidural needle is used to identify the
epidural space.
 A spinal needle is then passed through the epidural
needle into the subarachnoid space and the
subarachnoid block performed.
 After the removal of the spinal needle, an epidural
catheter is placed that can be used subsequently

 The lower number of skin punctures  Pain during the

procedure and infections and hematomas.

Slavkovi Z, et al. Combined spinal-epidural technique: single-space vs double distant space technique.
Vojnosanit Pregl 2013; 70(10): 953–8.
Slavkovi Z, et al. Combined spinal-epidural technique: single-space vs double distant space technique.
Vojnosanit Pregl 2013; 70(10): 953–8.
Double distance Space (DDS)

 Separate needle : use two separate needles needles to perform

the spinal and epidural components of the CSE. Both needles can
be inserted at the same vertebral interspace or separate
interspaces. Again, the spinal and epidural components of the
CSE can be performed in either order.
 The advantage of performing the spinal component first is that the
almost instantaneous onset of analgesia reduces the risk of the
patient moving during the subsequent insertion of the epidural
needle.

Slavkovi Z, et al. Combined spinal-epidural technique: single-space vs double distant space technique.
Vojnosanit Pregl 2013; 70(10): 953–8.
Slavkovi Z, et al. Combined spinal-epidural technique: single-space vs double distant space technique.
Vojnosanit Pregl 2013; 70(10): 953–8.
 Studies comparing the needle-through-needle technique
with the separate needle technique have found a higher
rate of failure of the spinal component with the needle-
through-needle technique  Failure rates of 5 – 20% have
been reported for the needle-through-needle technique,
compared with 5% for the separate needle technique.

On the other hand, the needle-through-needle

technique is associated with greater patient satisfaction
and may be quicker to perform

Slavkovi Z, et al. Combined spinal-epidural technique: single-space vs double distant space technique.
Vojnosanit Pregl 2013; 70(10): 953–8.
Aim

 Primary Outcome: compare the single space (“needle-

through- needle”) technique (SST) and the double distant
space technique (DDS) with regards to the time needed
for the procedure.

 The time needed for the CSE procedure was defined as

the time from skin preparation until successful epidural
catheter placement.

 Secondary Outcome: patient discomfort during the

procedure and patient's preference technique technique
of choice for postoperative pain management.

Slavkovi Z, et al. Combined spinal-epidural technique: single-space vs double distant space technique.
Vojnosanit Pregl 2013; 70(10): 953–8.
 Methods

 Prospective, Randomized, Single blinded clinical trial

 Approved by the University Expert Council for Medical

Science and written informed consent was obtained
from all patients before they entered the study.

Slavkovi Z, et al. Combined spinal-epidural technique: single-space vs double distant space technique.
Vojnosanit Pregl 2013; 70(10): 953–8.
 Methods
Exclusion criteria :
Inclusion criteria :
- Patient refusal to participate.
• Scheduled surgery for
- Significant cardiac, pulmonary,
resection of rectal hepatic
carcinoma. or renal comorbidity.

• Absence of - Preoperative opioid or non- steroidal

metastatic disease. anti inflammatory drugs (NSAID) use.

• The need for - Allergy to medications used in the

study.
intraoperative and
postoperative - Any contraindication to neuraxial
epidural analgesia. anesthesia.

- Drug addiction, psychiatric

disorders.

- spinal and neurological

problems
Slavkovi Z, et al. Combined spinal-epidural technique: single-space vs double distant space technique.
Vojnosanit Pregl 2013; 70(10): 953–8.
 All the patients received premedication with midazolam 2.5 mg iv, fluid preload
with Hartman’s solution 1 L, and antibiotic prophylaxis with ceftriaxone 2 g and
metronidazole 500 mg. All neuraxial blocks were performed in the operating room
with the patients awake, in the right lateral decubitus position.

78 Grup
A computer px DDT
generated
randomization 156 General
schedule was
provided to two px Anesthesia
independent
investigators
who preformed 78 Grup
all blocks
px SST

Slavkovi Z, et al. Combined spinal-epidural technique: single-space vs double distant space technique.
Vojnosanit Pregl 2013; 70(10): 953–8.
 DDS • In the DDS technique ( an epidural catheter was
inserted at the T6–7 or T7–8 interspace via a
paramedian approach [Perifix (18G Tuohy needle
and 20G standard epidural catheter); B. Braun,
Melsungen AG, Germany].

• Lidocaine 2% combined with epinephrine 1 :

200,000, 3 mL total, were administered via the
epidural catheter as test dose.

• In addition, all the patients received a

subarachnoid injection of morphine 200 g,
fentanyl 25 g and bupivacaine 2 mg (0.8 mL of
0.25% solution) at the L2– 3 interspace via a 25 G
spinal needle [Pencan (B. Braun, Melsungen AG,
Germany)].

avkovi Z, et al. Combined spinal-epidural technique: single-space vs double distant space technique.
ojnosanit Pregl 2013; 70(10): 953–8.
Slavkovi Z, et al. Combined spinal-epidural technique: single-space vs double distant space technique.
Vojnosanit Pregl 2013; 70(10): 953–8.
SST
 The SST was performed at the L2–3 interspace
using an Espocan needle (B. Braun Medical
Inc., Bethlehem, PA, 18 Ga-Espocan Tuohy
needle, Perifix epidural catheter 0.85 0.45 mm,
length 100 mm, 27–Ga Pancan Pencil Point
spinal needle).

 After epidural space identification, the spinal

needle was advanced, and medications
(morphine 200 g, fentanyl 25 g and
bupivacaine 2 mg (0.8 mL of 0.25% solution)
were injected in the subarachnoid space.

 The epidural catheter was advanced.

Lidocaine 2% with epinephrine 1 : 200,000 3 mL
total was given via the epidural catheter as test
dose to confirm appropriate catheter
placement.

 Bupivacaine 0.25% 10 mL was administered

through the epidural catheter, and sensory
blockade level was measured by pinprick at
the midclavicular line approxi- mately 20
minutes later. At a minimum, sensory blockade
from T6 to L1
 Statistical Analysis

 Data were analyzed using t-test and Chi Square.

 Correlation was assessed with Spearman’s.

 Data analysis using the SPSS statistical software

package, version 12.0.

 P-value less than 0.05 were considered statistically

significant.

Slavkovi Z, et al. Combined spinal-epidural technique: single-space vs double distant space technique.
Vojnosanit Pregl 2013; 70(10): 953–8.
RESULTS
Slavkovi Z, et al. Combined spinal-epidural technique: single-space vs double distant space technique.
Vojnosanit Pregl 2013; 70(10): 953–8.
Slavkovi Z, et al. Combined spinal-epidural technique: single-space vs double distant space technique.
Vojnosanit Pregl 2013; 70(10): 953–8.
Slavkovi Z, et al. Combined spinal-epidural technique: single-space vs double distant space technique.
Vojnosanit Pregl 2013; 70(10): 953–8.
Discussion

 The study was designed to evaluate the potential

benefits of double space vs single space (needle-
through-needle) CSE technique, and the time needed
to perform the CSE procedure.
 However, the time needed for the CSE procedure did
not differ between the two techniques.
 Similarly, an earlier study comparing three different
techniques (CSE set with an interlocking device
between the spinal and epidural needle vs CSE set
with a "back eye" at the epidural needle curve vs a
double-segment technique) found no difference in
the time needed to perform the block.

Slavkovi Z, et al. Combined spinal-epidural technique: single-space vs double distant space technique.
Vojnosanit Pregl 2013; 70(10): 953–8.
Conclusion

 There is no significant difference between the DDS and SST

regarding the time needed to perform the CSE procedure.

 In the SST group, body habitus, spinal landmarks and the anatomy
influenced the number of epidural punctures.

Slavkovi Z, et al. Combined spinal-epidural technique: single-space vs double distant space technique.
Vojnosanit Pregl 2013; 70(10): 953–8.
25 Pertanyaan Klinis

Apakah ada perbedaan waktu yang

diperlukan untuk prosedur CSEA dengan
teknik SST vs DST?
 Formulasi Pertanyaan Klinis dalam PICO
Penelusuran Bukti
26 / Problem Intervention/
Patient Comparison Outcome
/ Population Indicator/
Index

156 patients general SST vs DST The epidural catheter was

undergoing anesthesia and used for postoperative
colo- rectal CSE. All neuraxial analgesia for 72 hours. Body
surgery under blocks were habitus, spinal anatomy
general performed and spinal landmarks were
anesthesia and before general assessed preoperatively.
CSE. anesthesia The number of epidural and
induction. spinal punctures, the feeling
that the dura is perforated
(dural perforation click) and
the time needed to perform
CSE were also recorded.
27

JOURNAL APPRAISAL
Kelengkapan Artikel
28

 Judul
 Pengarang dan Institusi
 Abstrak
 Pendahuluan
 Metode LENGKAP
 Hasil
 Diskusi
 Daftar Pustaka
Desain Penelitian, Fokus dan Worksheet
29

 Desain Penelitian : Eksperimental

 Fokus Jurnal : Terapi
 Worksheet yang digunakan : Terapi
30

VALIDITY
(RAMMBO)
 Telaah
Validity Sesuai
RAMMBO Jawaban Work- Bukti
31 Worksheet sheet
Terapi
1. Recruit Apakah YA Inclusion criteria :
ment subjek • Scheduled surgery for resection of
mewakili? rectal carcinoma.
• Absence of metastatic disease.
• The need for intraoperative and
postoperative epidural analgesia.
Exclusion criteria :
- Patient refusal to participate.
- Significant cardiac, pulmonary, hepatic or
renal comorbidity.
- Preoperative opioid or non- steroidal anti
inflammatory drugs (NSAID) use.
- Allergy to medications used in the study.
- Any contraindication to neuraxial
anesthesia.
- Drug addiction, psychiatric disorders.
- Spinal and neurological problems
 Telaah
Validity Sesuai
RAMMBO Jawaban Work- Bukti
32
Worksheet sheet
Terapi
2. Allocation Apakah YA ( Methods, pg. 11)
penempatan
I & C diacak
dan A computer generated randomization schedule
disembunyi was provided to two independent investigators
kan? who preformed all blocks: the investigator one
Sehingga performed all DDS procedures, while the
kelompok- investigator two performed all SST procedures. The
kelompok I patients were blinded to the group assignment.
&C
sebanding
pada awal
percobaan?
 Telaah Validity
Sesuai
Jawaban
RAMMBO Work- Bukti
33 Worksheet sheet
Terapi
3. Apakah YA All the patients received pre-medication with
Mainten kelompok- midazolam 2.5 mg iv, fluid preload with
ance kelompok Hartman’s solution 1 L, and antibiotic prophylaxis
memperoleh with ceftriaxone 2 g and metroni dazole 500 mg.
kointervensi All neuraxial blocks were performed in the
yang sama? operating room with the patients awake, in the
apakah ada right lateral decubitus position.
kecukupan tindak
lanjut?
 Telaah Validity
Jawaban Sesuai
RAMMBO Bukti
Work-sheet
34 Worksheet
Terapi
4. Apakah subjek YA A computer-generated randomization
Measurement dan penilai schedule was provided to two independent
Blinding disamarkan investigators who preformed all blocks: the
Outcome terhadap
investigator one performed all DDS
perlakuan yang
diterima dan/atau procedures, while the investigator two
apakah performed all SST procedures. The patients
pengukurannya were blinded to the group assignment.
objektif?
35

IMPORTANCY
 Telaah
Importancy
36 Jawaban sesuai Worksheet
Worksheet
Terapi
Apakah Ya,
kemaknaan Results. Epidural and subarachnoid spaces were
successfully identified in all the patients. Duration of CSE
statistik dan procedure, the number of spinal punctures, dural click
kemaknaan feeling and the effects of test dose did not differ between
the groups. The patients in both groups (90% of DDS and 87%
klinis dari
of SST) would choose CSE as preferred method in the future
hasil The CSE procedure was painful for 16% of DDS vs 20% of SST
penelitian patients. A significant correlation between time needed fo
CSE technique performance and body habitus (r = 0.338, p
tergambar 􏰑 0.01), spinal landmarks (r = 0.452, p 􏰑 0.001) and
dengan baik? anatomy (r = 0.265, p 􏰑 0.05) was found in the SST group
There was no correlation between the number o
epidural/spinal punctures and epidural bacteriologica
findings. There was no correlation between the patients’
choice of the CSE technique and the number of spina
punctures, duration of CSE procedure and epidural cathete
stay
37

APPLICABILITY
38
No Telaah Applicability Jawaban

Apakah PICO jurnal yang diperolehsesuai PICO

1. Ya
pertanyaanklinis?
Apakah pasien anda cukup mirip dengan pasien
2. Ya
dalam penelitian?
Apakah intervensi / indicator / indeks dalam
Ya
3. penelitian ini dapat diterapkan untuk manajemen
pasien di lingkungan anda?
Apakah outcomes penelitian ini penting bagi
4. Ya
pasien anda?
Akankah potensi manfaat lebih besar / indikator /
5. potensi merugikan bila intervensi / indikator / Ya
indeks ini diaplikasikan pada pasien anda?

Apakah hasil penelitian ini dapat diintegrasikan

6. Ya
dengan nilai-nilai serta harapan pasien anda?
Kesimpulan
39

 Penelitian yang dilaporkan dalam jurnal

tersebut VALID
 IMPORTANCY dalam penelitian tersebut
tergambar dalam jurnal.
 Hasil penelitian yang dilaporkan dalam
jurnal tersebut bersifat APPLICABLE untuk
pasien.
40

TERIMA KASIH