Meg Carman DNP, ACNP-BC, ENP-BC, FAEN Melinda Johnson, MSN, FNP-BC, AGACNP-BC, ENP-C. performing lumbar puncture (LP) in the emergency care setting

Transcription

1 Lumbar Puncture Meg Carman DNP, ACNP-BC, ENP-BC, FAEN Melinda Johnson, MSN, FNP-BC, AGACNP-BC, ENP-C Objectives 1. Identify indications, contraindications, and considerations for performing lumbar puncture (LP) in the emergency care setting 2. Demonstrate appropriate technique for locating anatomic landmarks for LP in both pediatric and adult patients 3. Demonstrate appropriate technique for performing lumbar puncture using US guidance in both pediatric and adult patients 4. Interpret findings of cerebrospinal fluid obtained through LP and apply these in the clinical setting 1

2 Clinical Indications for LP Diagnostic Bleeding (subarachnoid hemorrhage) Infection (Meningitis, encephalitis) Neoplasm Therapeutic Pseudotumor cerebri Contraindications Elevated ICP Platelets - Absolute: <20,000 - Relative: 20,000-50,000 Skin infection over LP site Anticoagulation Hemophilia, von Willebrands, other coagulopathies Trauma to lumbar spine 2

3 Consent Benefits: Diagnosis Measurement of ICP Pain relief Risks: Infection Pain Bleeding Spinal headache *Spinal Hematoma May be unable to obtain CSF Pre-procedural Considerations Comorbidities Coagulopathies Brain lesions Immunosuppression Medications Anticoagulation/Antiplatelet Therapy Immunomodulators/Immunosuppressants Labs PT/PTT, platelets WBC, differential 3

4 Pre-procedural Considerations Anxiety Ability to cooperate Hydration status Positioning Positioning By Blausen.com staff, "Blausen gallery 2014", Wikiversity Journal of Medicine, via Wikimedia Commons 4

5 Pediatric Positioning Lateral Recumbent - Most frequently used - Neck flexed, knees drawn up to chest by assistance of a holder - Goal to open up interspinous spaces - Hips and shoulders perpendicular to exam table - Gluteal crease aligned with spinous processes Pediatric Positioning Sitting May be preferred if concern for respiratory compromise May improve flow of CSF in very small infants <2wks age Cannot measure opening pressure accurately 5

6 Anatomic Landmarks Pediatric Anatomical Landmarks LP should be performed - Distal to the spinal cord, - Level of cauda equina Infants <12 months - Below L2-L3 through L5-S1 Children >12 months - L2-L3 through L5-S1 ~L4 is approximately where an imaginary line connects the top of the posterior iliac crests 6

7 Pediatric Analgesia & Anesthesia Oral Sucrose Reduce procedural pain in infants <6mos Offer on pacifier Procedural Sedation Older, apprehensive children Those unable to tolerate positioning for the procedure Topical Anesthesia If LP not time sensitive Requires min to be effective EMLA or LMX Local Anesthesia 1% lidocaine 25g needle Wheal over interspace, then infiltrate subcutaneous tissue May obscure landmarks Sterile Prep & Draping 1-2 pkg. Sterile drapes - Kits typically have (annoying) inadequate paper drapes Gown Mask Sterile gloves 7

8 Sterile Prep & Draping (Self gown and glove video) Supplies Povidone iodine 1% preservative free lidocaine 3 ml syringe/needle Gauze Manometer/extension tubing Labeled tubes g styletted needle <2 years 1.5 Between 2-12 years 2.5 >12 years 3.5 Accessed 1/11/2018 at: -by-carefusion/lumbar-puncture-trays/z05-pf

9 Ultrasound Guidance Linear Array vs curvilinear probe Sonosite video: US guided lumbar puncture: LP Procedure 1. Prepare tray, setting up tubes in correct numerical order 2. After sterile prep and drape, clean area in circular manner three times, inner to outer 3. Reassess landmarks using US (preferred) or palpation 4. Anesthetize intradermal area first with 1% lidocaine, then extend needle into the SQ tissue, pulling back on syringe to avoid vascular structures 9

10 LP Procedure 5. Assess local sensation,*patient will still feel pressure 6. Needle Position Position US Probe over site, rotating for longitudinal view - Bevel up, positioned to face patient s flank Allows spreading, rather than cutting of dural sac Logitudinal to collagen fibers 7. Introduce spinal needle into L4-5 interspace with stylet in place - Angle slightly cephalad toward umbilicus * If sudden radicular pain, needle is too far lateral Withdraw & start again - With sudden release or popping sensation (ligamentum flavum), you are in the subarachnoid space LP Procedure 8. Withdraw stylet, observing for drip/flow of CSF Crying, cough, deep breathing may promote flow 9. Attach manometer with stopcock off to open end, measure in lateral recumbent position 10. Collect sample in sequential tubes 11. Replace stylet 12. Remove in one smooth motion, apply pressure and bandaid EMRAP video on Lumbar puncture: 10

11 CSF Analysis Tube #1- Cell Count Tube #2- Chemistries Tube #3- Culture and sensitivity Tube #4- Repeat Cell count CSF Interpretation Analysis of CSF should be coordinated with patient history, physical exam, and in coordination with other tests Non-infectious findings, xanthochromia, RBC s WBCs Protein Glucose Bacterial Elevated; PMNs Elevated Decreased Viral Normal to Low; lymphocytes Normal to mildly increased Normal Fungal Normal to slight increase; PMNs, lymphocytes Normal to slight increase Normal to slight decrease 11

12 Post Procedure Considerations No studies to suggest bed rest superior to immediate mobilization post LP to reduce risk of post-lp headache No specific period of observation, no pediatric restrictions post-procedure Discharge instructions Signs/Symptoms of spinal headache Neurologic compromise Hydration Infection Summary Lumbar puncture is a procedure commonly performed in emergency care, primarily for diagnosis Clinical judgement is essential: consider appropriateness of procedure, technical approach, interpretation of results Ultrasound is rapidly becoming the standard of care in performing LP; obtain formal training and practice 12

13 References Ahmed, S.V., Jayawarna, C., Jude, E. (2006) Post lumbar puncture headache: Diagnosis and management. Postgraduate medical journal, 82(973) : Ladde, J.G. (2016). Central nervous system procedures and devices. In Tintinelli s Emergency Medicine: A Comprehensive Study Guide (8th ed). McGraw-Hill, New York. UpToDate. Lumbar puncture: Indications, contraindications, technique, and complications in children. Retrieved January 11, 2018 from rank=1#h11 UpToDate. Lumbar puncture: Technique, indications, contraindications, and complications in adults. Retrieved January 11, 2018 from 13