Would you perform CSE vs. spinal vs. epidural in a patient with ESRD?

This is a controversial topic, with many varying opinions in the literature. Some of the advantages of the CSE include solid spinal block for surgery, the higher epidural catheter success rate than when an epidural only is placed, as well as the ability to offer the patient postoperative analgesia, compared to the finite duration of a spinal alone. The higher reported catheter success rate with CSE’s has an intuitive anatomical foundation.

Anatomically speaking, the cerebrospinal fluid obtained from the spinal needle which is passed through the Tuohy needle is a confirmatory sign that the Tuohy needle should have passed through the epidural space. Intraoperative use of epidural anesthesia, with any of these three techniques, has been shown to decrease intraoperative blood loss as well as decrease the risk of perioperative thromboembolism and fatal pulmonary embolism and improve bowel function post op. The decreased intraoperative blood loss has been demonstrated for a wide range of surgical procedures is postulated to be due to absence of venous congestion and high hydrostatic pressure (as seen with positive pressure ventilation under general anesthesia).