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HWN Suggests

Positioning for Lumbar Puncture

I am likely jinxing myself (and anyone working in the Peds ED while reading this… sorry), but it is useful (at least I think so). Just close your eyes and imagine that it is 0530hrs and a 3 week old pops up on the board with the word “Fever” in the complaint column. You “spring” into action: H+P, Labs ordered, Abx ordered, and bed requested. Then you look around and find the “best holder,” because we all know that these little ones squirm. The kid appears well enough, except for the copious snot flowing from the nares… making you glad not to be near the face during the procedure. The master holder takes the child and “crunches” them into a near circle (head nearly touching toes). You begin…

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Featured

 To LP, or not to LP (the febrile infant): That is the question

Please forgive my modern adaptation of a classic Shakespearian soliloquy, but it does seem that we have been struggling with the conundrum of the febrile infant for a very long time. To miss a serious bacterial infection (SBI), defined as urinary tract infection, bacteremia, and bacterial meningitis, can have serious consequences.

Articles of Interest

Traumatic Lumbar Punctures in Infants 1 to 2 months

The SBI rate did not differ between the normal LP and the traumatic and unsuccessful LP infants.

For Pediatric Lumbar Punctures, Stylet In or Out?

After insertion of the LP needle through the epidermis and subcutaneous tissue with the stylet in, advancing stylet out appears to improve LP success in children.

How to Perform a Lumbar Puncture

Orientate the needle with the bevel parallel to the spine so it will separate the longitudinally running fibres of the Dura. (I think this feels natural in the left lateral position but requires more thought in the sitting position).

How to succeed on your next Lumbar Puncture

Early stylet removal – able to appreciate CSF flash when in spinal canal.

How to use… lumbar puncture in children

Lumbar puncture (LP) is a useful diagnostic tool in a wide spectrum of paediatric clinical situations. A common indication is to rule out a serious intracranial infection in a febrile child. Success rate can be optimised by proper positioning, appropriate technique and enhanced operator’s skill in performing the procedure. The purpose of this review is to explore the indications and contraindications for performing paediatric LP, to describe the anatomical and physiological knowledge required to maximise success rates and to describe complications and their management. We will also provide advice on requesting various cerebrospinal fluid studies, interpretation of results and clinical situations in which LP may be indicated.

I would like to know what kind of procedural sedation is normally used

I guess oral sucrose is commonly used in infants. Does most of the provider get ketamine for sedation in older age group? Do they sometimes just use local numbing like LET or lidocaine SQ?

Intravenous Fluid Bolus Prior to Neonatal and Infant Lumbar Puncture

Neonatal and infant lumbar puncture is a commonly performed procedure in emergency departments, yet traumatic and unsuccessful lumbar punctures occur 30% to 50% of the time. Dehydration may be a risk factor for unsuccessful lumbar punctures, but to our knowledge, no studies have investigated the use of intravenous (IV) fluid bolus prior to lumbar puncture.

Lumbar Punctures in Febrile Infants with Positive Urinalysis - It's Just Overkill

Among noncritical febrile infants ≤ 60 days of age with positive UA results, there were no cases of bacterial meningitis in those aged 29 to 60 days and no cases of bacteremia and/or bacterial meningitis in any low-risk infants based on low-risk blood thresholds in both months of life. These findings can guide lumbar puncture use and other clinical decision making.

Pediatric febrile seizure: When do I need to do a lumbar puncture?

A simple febrile seizure does not require further diagnostic evaluation (beyond simply working up the fever) or an LP.

Perfecting your pediatric lumbar puncture using ultrasound

A lumbar puncture (LP) is a common procedure that every emergency physician must master. Pediatric LPs can be challenging for even the most experienced clinician due to small anatomy, difficulty with patient cooperation, and lack of frequency performed.

Post Lumbar Puncture Headache - Peds

Post Lumbar Puncture (AKA, Post Dural Puncture) Headache is one of the most common complications of the LP.

Safety and Success of Lumbar Puncture in Young Infants: A Prospective Observational Study

LP was safe in most infants. Body weight or GA at LP did not affect LP failure. These data are useful to clinicians, providing information on the safety of the procedure.

The Physician Doth LP Too Much, Methinks

Overall, this study is consistent with the growing body of evidence recommending a less aggressive septic workups (urine, blood, and cerebrospinal fluid analysis) in well-appearing febrile infants.

Traumatic Lumbar Puncture

For every 500 (or 1,000) RBCs in the CSF, you can have 1 WBC in the CSF.

Video - An Approach to Lumbar Punctures

This video highlights an approach to lumbar punctures.

Video - Lumbar Puncture – Pediatric or Infant

Video developed by Augusta University.