Lumbar puncture: Difference between revisions
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#Sterile prep L3-L4 and L4-L5 interspaces; prepare and confirm correct tubes in numerical order | #Sterile prep L3-L4 and L4-L5 interspaces; prepare and confirm correct tubes in numerical order | ||
#*U/S can be used to ID interspaces in obese patients increasing your accuracy as much as 2.3 times<ref> Nomura, J, et al. A randomized control study of ultrasound-assisted lumbar puncture. J Ultrasound Med. 2007; 26:1341–8.</ref> | #*U/S can be used to ID interspaces in obese patients increasing your accuracy as much as 2.3 times<ref> Nomura, J, et al. A randomized control study of ultrasound-assisted lumbar puncture. J Ultrasound Med. 2007; 26:1341–8.</ref> | ||
#*Aim lower than L4-L5 and no higher in pediatric patients as the conus medullaris ends at L3 at birth<ref>Gupta A and Usha U. Spinal anesthesia in children: A review. J Anaesthesiol Clin Pharmacol. 2014 Jan-Mar; 30(1): 10–18.</ref> | |||
#*Tuffier's line, L5/S1 at iliac crests in the pediatric patient<ref> | |||
#Positioning | #Positioning | ||
#*Patient on side: able to measure opening pressure | #*Patient on side: able to measure opening pressure | ||
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#Opening pressure should be measured with patient on side with legs extended | #Opening pressure should be measured with patient on side with legs extended | ||
#Collect 1mL of CSF in each tube | #Collect 1mL of CSF in each tube | ||
[[File:Pediatric_spinal_cord.JPG|thumbnail]] | |||
==CSF Studies== | ==CSF Studies== | ||
Revision as of 07:59, 15 March 2017
Indications
- Suspicion of meningitis [1]
- Suspicion of subarachnoid hemorrhage (SAH) [2]
- Suspicion of certain central nervous system (CNS) diseases such as Guillain-Barré syndrome [3]
- Therapeutic relief of pseudotumor cerebri [4]
Contraindications
- Infection at LP site
- Suspected spinal epidural abscess
Lumbar puncture if coagulopathic
- Tranfuse if platelets <25,000[5][6]
- INR >1.5
- Hemophilia, von Willebrand disease, other coagulopathies
- If hemophiliac, replace factor before LP
CT Before Lumbar Puncture
LP without CT is likely safe if:[7]
- History
- Age < 60
- Not immunocompromised
- No history of CNS disease
- No seizure within 1 week of presentation
- Physical Exam
- No altered level of consciousness
- Ability to answer two consecutive questions successfully
- Ability to follow two consecutive commands successfully
- Normal neurologic exam
- No altered level of consciousness
If none of the above, chance of normal ct is 97%; none of the patients herniated
CT findings that prohibit LP:[8]
- Midline shift
- Unequal pressures between the 3 cerebral compartments (left/right supretentorial compartments, posterior fossa)
- Intracerebral masses not causing midline shift
- Obstructive Hydrocephalus
- Enlargement of ventricles prox to lesions and normal ventricles distal (especially 4th ventricle)
- Basilar cisterns compressed
- Lateral/3rd ventricles may be small due to diffuse cerebral edema or enlarged due to obstr. hydroceph. +/- shift
- Posterior fossa mass
- Displacement/compression of 4th ventricle
Procedure
- Sterile prep L3-L4 and L4-L5 interspaces; prepare and confirm correct tubes in numerical order
- U/S can be used to ID interspaces in obese patients increasing your accuracy as much as 2.3 times[9]
- Aim lower than L4-L5 and no higher in pediatric patients as the conus medullaris ends at L3 at birth[10]
- Tuffier's line, L5/S1 at iliac crests in the pediatric patientCite error: Closing
</ref>missing for<ref>tag[11]
- 12 hrs after antibiotics: CSF glucose levels increase and protein levels decrease. CSF WBC and neutrophils are not affected[12]
Complications
External Links
See Also
References
- ↑ CDC: Meningitis
- ↑ Carley, S. Harrison, M. Timing of lumbar puncture in suspected subarachnoid haemorrhage. Emerg Med J 2005;22:121-122
- ↑ Petzold A, Brettschneider J, Jin K, et al. CSF protein biomarkers for proximal axonal damage improve prognostic accuracy in the acute phase of Guillain-Barré syndrome. Muscle Nerve. 2009 Jul. 40(1):42-9
- ↑ Chern JJ, Tubbs RS, Gordon AS, Donnithorne KJ, Oakes WJ. Management of pediatric patients with pseudotumor cerebri. Childs Nerv Syst. 2012 Jan 19
- ↑ Howard SC, Gajjar A, Ribeiro RC, et al. Safety of lumbar puncture for children with acute lymphoblastic leukemia and thrombocytopenia. JAMA 2000; 284:2222–2224
- ↑ Vavricka SR, Walter RB, Irani S, Halter J, Schanz U. Safety of lumbar puncture for adults with acute leukemia and restrictive prophylactic platelet transfusion. Ann Hematol 2003; 82:570–573
- ↑ Computed Tomography of the Head before Lumbar Puncture in Adults with Suspected Meningitis. NEJM 2001; 345; 1727-33
- ↑ Emergency Radiology: Case Studies Schwartz
- ↑ Nomura, J, et al. A randomized control study of ultrasound-assisted lumbar puncture. J Ultrasound Med. 2007; 26:1341–8.
- ↑ Gupta A and Usha U. Spinal anesthesia in children: A review. J Anaesthesiol Clin Pharmacol. 2014 Jan-Mar; 30(1): 10–18.
- ↑ Michael B1, Menezes BF, Cunniffe J, Miller A, Kneen R, Francis G, Beeching NJ, Solomon T. Effect of delayed lumbar punctures on the diagnosis of acute bacterial meningitis in adults. Emerg Med J 2010;27:6 433-438. PMID 20360497
- ↑ Lise E. Nigrovic, Richard Malley, Charles G. Macias, John T. Kanegaye, Donna M. Moro-Sutherland, Robert D. Schremmer, Sandra H. Schwab, Dewesh Agrawal, Karim M. Mansour, Jonathan E. Bennett, Yiannis L. Katsogridakis, Michael M. Mohseni, Blake Bulloch, Dale W. Steele, Ron L. Kaplan, Martin I. Herman, Subhankar Bandyopadhyay, Peter Dayan, Uyen T. Truong, Vince J. Wang, Bema K. Bonsu, Jennifer L. Chapman, Nathan Kuppermann. Effect of Antibiotic Pretreatment on Cerebrospinal Fluid Profiles of Children With Bacterial Meningitis. Pediatrics Oct 2008, 122 (4) 726-730. PMID 18829794