journal lumbar punctures, nila.pptx

7/28/2019 Journal Lumbar punctures, nila.pptx

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LUMBAR PUNCTURES: USE AND

DIAGNOSTIC EFFICIENCY

IN EMERGENCY MEDICAL DEPARTMENTS

Bilal Majed & Hlne Zephir &

Valrie Pichonnier-Cassagne & Yazdan Yazdanpanah & Philippe

Lestavel & Pierre Valette & Patrick Vermersch

JURNAL READING

Dipresentasikan oleh :

Estu Nila Widuri, dr

Pembimbing :

Paulus Sugianto, dr, Sp.S


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Abstract

Background

LP regularly and effortlessly used in the

emergency medical epartments (EMD).

LP use and efficiency have not been fullyexplored in the published literature.

Aims

to assess in a French EMD, the frequency

of use and the diagnostic efficiency of LP, the

final diagnoses, and related medical practices


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Methods

Retrospective

all patients who underwent an LP after admission

to adult EMD 2004 - 2005.

Patients medical files were reviewed to collect

clinical and paraclinical features.

We defined efficient LP as abnormal LP, whichconfirmed a suspected diagnosis in an emergency

setting.

Abstract


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Results

247 patients

LP were efficient in fewer than 15% ofcases and confirmed aseptic

meningitis (8.5%), bacterial meningitis

(2.4%), Guillain-Barr syndromes(1.6%), subarachnoid hemorrhages

(SAH, 0.4%), and carcinomatous

meningitis (0.4%).

Abstract


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The principal differential diagnoses wereinfections outside the central nervoussystem (CNS, 30%), noninfectious

neurological disorders (28.7%), andbenign headaches (14.2%). The mainassumed LP indications were to search forCNS infection (62%) and for SAH (25%).

LP efficiency decreased dramaticallyaccording to patients age.

Abstract


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Brain imaging was performed in 90% of

patients prior to LP.

Excessive use of PCR to detect herpes

simplex in cerebrospinal fluid was

observed.

LP complications found were postdural

puncture headaches (6.1% of cases).

The rate of traumatic LP was 17%.

Abstract


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Our results are in accordance with the

few published surveys on this topic.

LP efficiency is modest but must be

considered in light of the seriousness

of suspected diagnoses.

However, the search for differential

diagnoses should not be neglected.

Abstract

Conclusions


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Introduction

Efficient diagnosis strategies (usingLP) are required for EMD patientswith suspected meningitis, SAH or

GBS. LP use and efficiency have not been

fully explored in the publishedliterature

none of the published studies usedFrench populations.


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infrequently supported by LP results

in the EMD missed diagnoses of

SAH in the EMD have been reported

need for further investigations toexplore the use and the efficiency of LP

performed in the EMD.

The main associated investigations,

such as CT of the brain prior to LP, and

CSF tests, are also important to assess.

SAH and GBS


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lack of published literature on the use of

LP in the EMD

conducted an observational retrospective study

frequency of LP use in an emergency setting,

the diagnostic efficiency of LP,

and the usefulness of CSF tests.

also assessed medical practices

associated with the use of LP, such as

performing a CT scan prior to an LP; LP

complications were also investigated


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Material and methods

retrospective study

all patients who underwent an LP in the adultsEMD a general hospital in Arras, in the north of

France,

Between January 2004 and December 2005.

during the phase of care in the EMD

Were collected patients clinical, biological,

and brain imaging findings.

Population studied


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assessed the frequency of LP use in ourEMD compared to the number of

admissions (in 2004 and 2005)

We reviewed the medical files of theselected patients.

Final diagnoses, patients clinical features,

CSF test findings, and the other paraclinicalexplorations (CT) were assessed and

entered in a database.

Methods


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assess LP indications and final diagnoses

using independent examinations ofpatients medical files performed by two

emergency physicians

a descriptive analysis to explore

patients features and to assess

associations with final diagnoses.

Efficient LP were defined as abnormal LP,

which confirmed suspected specific

diagnoses in an emergency setting

(infections of the CNS, SAH, and GBS)


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Proportions were computed with

confidence intervals of 95% (95% CI) and

chi-square tests Standard CSF test findings were

compared according to the type of

meningitis diagnosed :

aseptic (lymphocytic) or

Bacterial

expected modest efficiency of LP in theEMD nonparametric tests were used S-Plus statistical software was used for

the data analysis.


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Results

total of247 patients from 46,483

admissions during January 2004 -

December 2005

Monthly the proportion varied widely,

from a minimum of 0.24% to a maximum of

0.94%. no significant difference was found that

could indicate a possible seasonal

variation in the use of LP (p=0.28).

Frequency of LP use


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median age 52 years (3672),

sex ratio (male to female) 1.12.

Patients clinical features


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The main sites reported suggestive

of infections outside the CNS werepulmonary, urinary, and in the upper

respiratory tracts

Pulmonary and urinary sites were

more frequently observed among

elderly patients, whilst upperrespiratory tract sites were more

often reported among young and

middle-aged patients


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the youngest patients more

frequently presented with benign viral

infections (7.1% of all diagnoses)and benign headaches (30.4%).

They also presented with fewernoninfectious neurological disorders:

16% of final diagnoses versus 38%

among middle-aged patients and30% among elderly patients

(p


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LP efficiency and CSF tests

Contributive LP represented 13.4%

(95% CI: 9.117.6) of the cases and

varied significantly according topatients age: the proportion of

efficient LP decreased from 25%

among young patients to 14.2%among middle-aged patients and to

less than 5% among elderly patients


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Table 2 Comparison of biological test characteristics

(medians) between bacterial and lymphocytic/aseptic

meningitis (p value according to nonparametric tests)


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Medical practices and complications

related to LP use

Almost all patients underwent a CT prior to the LP

[89.9% (86.194.6)], independently of LP indications

(table 1)

When LP were performed within the first 24 h after

admission, the median delay between admission and

cranial CT was 2 h; the median delay for patients

admitted between midnight and 6 A.M. was 7 h

The median delay between admission and LP results

was 6 h, whereas delays of up to 10 h were recorded forsome of the patients admitted between midnight and 6

A.M.


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A positive correlation was found between

the delay before cranial CT and the delay

before obtaining LP results: the correlation

coefficient was 0.6 (p


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Discussion

Among efficient LP, aseptic (lymphocytic)meningitis was the most frequent diagnosis,

whereas the search for an infection of the CNS

was the most frequent indication for LP.

Thus, patients could benefit from optimaltreatments and strategies of care, based upon

the results of CSF analyses.

In cases of ineffective LP, the principaldifferential diagnoses were infections outside the

CNS, noninfectious neurological disorders

(seizures and strokes), and benign headaches.


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Though LP efficiency decreased

dramatically according to age,

differential diagnoses (diagnoses foundin cases of inefficient LP) also varied

substantially according to patients age.


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Considering the seriousness of meningitis,

SAH, and acute GBS disorders, which

may compromise patients functional andvital prognoses, LP represent a consistent

tool to rule out SAH or meningitis and to

support a diagnosis of suspected acute

GBS in an EMD setting


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Our results were in line with the findings of

the few published studies exploring LP use

and efficiency in EMD settings

Mdol et al.Powers and Warshaw et al.

Perry et al.s and McGillicuddy et al.s


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The commonest complication of LP is PDPH,

more serious complications have exceptionally

been observed:

cerebral herniation,

spinal hematoma,

iatrogenic spinal tumor,

induced meningitis.

The incidence of PDPH after a diagnostic

LP procedure can vary from 6 to 40%

Information not reported in patients files andearly discharge from the EMD to home (14% of

patients) represent potential mechanisms of

misclassification.


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Significant differences between aseptic and bacterial

meningitis were found in our study, when standard

CSF tests were considered

some authors have suggested that these standard

tests are only moderately useful in the event of a

negative Gram-stained smear

specific CSF and blood serum

tests have been proposed to

better appreciate the likelihood

of bacterial meningitis


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The usefulness of the occurrence of soluble

antigens in CSF was limited in our survey;

however, this CSF test was infrequentlyemployed (6% of CSF) in accordance with

published data

the rates of traumatic LP observed in ourstudy were similar to previously published

data by Shah et al

Among elderly patients, fewer than 5% of LP

were efficient, whilst almost four fifths of LP

were employed to search for a CNS infection


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Among elderly patients, fewer than 5% of LP were efficient,

whilst almost four fifths of LP were employed to search for a

CNS infection

The majority of infections detected among

elderly patients were principally located in

the respiratory or urinary tracts

Greater yield of LP was found among young (25% of

cases) and middle-aged patients (a little less than 15%

of cases).

Among these subpopulations, efficient LP

documented primarily infections of the

CNS (mainly aseptic meningitis)


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among younger patients

corresponded to a higherclinical suspicion of meningitis.

elderly patients to rule out the possibility of a CNS

infection.

LP indications

Clinical suspicion of CNS infection is assumed to

have differed widely between these subpopulations

and can explain the differences observed in LP

efficiency


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The usefulness of performing a CT prior to an LP

depends on the patients clinical condition and the

suspected diagnosis

in our study a brain CT prior to LP seems to be

routinely employed: clinical signs (focal neurological

signs, seizures, or abnormal consciousness) requiring a

brain CT prior to the performance of an LP were foundamong less than a third of our population

Unexpectedly, approximately 90% of patients who

underwent an LP to search for an infection of the CNS

had CT prior to LP. Significant delays have been

observed between admission, the brain CT, and LP

results, especially when admissions occurred between

midnight and 6 A.M.


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When LP are performed in order to search for

an infection of the CNS, ordering a CT prior

to an LP can lead to an important delay of theLP procedure.

Thus, administration of antibiotics may also

be delayed, compromising the prognosis of

patients with bacterial meningitis


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SAH is suspected...??

SAH diagnoses are more frequently confirmed using brain

imaging usually performed as the first-line diagnostic

tool

However, in spite of brain CT enhancement using fifthgeneration CT scanners, which improves the diagnosis of

SAH, the sensitivity of noncontrast CT imaging may,

in some cases, remain insufficient

the use of LP remains necessary to rule out SAH


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In our study, assumed SAH indications for LP represented

only 25.5% of the cases and only one case of SAH was

found using an LP.

SAH indications were more frequent among middle-aged

and young patients


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Several limitations, linked to the

retrospective nature of our study,must be considered when

assessing our results.

LP subsequently performed inhospitalization units after an initial

admission in the EMD were not

taken into account, leading to apotential selection bias.


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In this study, our aim was to assess emergency

medical practices in relation to patients initial

characteristics observed in the EMD.

Classification and information biases can result

from the retrospective reviewing of patients

medical files, leading to a more difficultassessment of patients features, indications for

LP, and final diagnoses.

Thus, two emergency physicians reviewed

patients medical files independently and theconcordance of our results with the literature

data suggests that these biases are limited.


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A better assessment of the efficiency of LP would

undoubtedly be achieved in a prospective setting with a

larger study population

This would allow a more precise and reliable assessment of

LP indications, patients features, delivery of anti-infective

treatments (in cases of suspected meningitis), andoutcomes during a follow-up.

Missed meningitis and SAH diagnoses, in the EMD, would

also be appreciated. The assessment of medical practices,illustrated by the use of brain CT prior to LP (in cases of a

possible infection of the CNS) and herpes simplex PCR

tests, suggests that the current published guidelines and

data were not fully taken into account


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A prospective survey would permit evaluation of

potential improvements in medical practices after a

review of current guidelines.

The assessment of medical practices, illustrated by the

use of brain CT prior to LP (in cases of a possibleinfection of the CNS) and herpes simplex PCR tests,

suggests that the current published guidelines and data

were not fully taken into account


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CRITICAL APPRAISAL


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1. Apakah terdapat ketersamaan

dengan Gold Standart?

Tidak diketahui

Di dalam jurnal ini tidak dijelaskan

mengenai sensitivitas, spesifitas, nilai

prediksi positif, nilai prediksi negatif, dan

prevalensi

jurnal ini hanya membahas mengenai

kegunaan dan efisiensi penggunaan LP diEM department dalam penegakkan suatu

diagnosis


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2. Apakah sampel subyek penelitian meliputi

spektrum penyakit dari yang ringan sampai berat,

penyakit yang terobati dan tidak terobati

Ya

Tampak pada Tabel 1 dimana peneliti telah

mencantumkan secara terperinci mengenaiusia, berbagai macam gejala klinis, dan

riwayat penyakit sebelumnya dari subyek

yang diteliti.


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3. Apakah lokasi penelitian disebutkan

dengan jelas?

Ya

Lokasi telah disebutkan secara jelas, yaitu

pada Adult Emergency Medical Department

di salah satu rumah sakit umum di Arras,Perancis Utara


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4. Apakah presisi uji diagnosa dan variasi

pengamat dijelaskan?

Iya

Dalam penelitian ini, variasi pengamat telah

dilakukan, namun tidak di jabarkan mengenai

fluktuasi hasil pengukuran/analisa ulang dari LP Tampak pada:

The retrospective design of our survey led us to

assess LP indications and final diagnoses usingindependent examinations of patients medical files

performed by two emergency physicians


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5. Apakah istilah normal dijelaskan?

Tidak

Terdapat penggunaan istilah normal

dalam pemeriksaan CSF dari LP, namun

tidak dijelaskan secara terperinci kriteria

normalnya.

Therefore, despite the modest efficiency ofCSF examinations revealed by our results,

negative or normal CSF findings can be

informative and useful


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6. Apabila uji diagnosis yg diteliti merupakan

bagian dari suatu kelompok uji diagnosa, apakah

kontribusinya pd kelompok uji diagnosa tersebut

dijelaskan?

Iya

LP merupakan suatu bagian dari suatukelompok uji diagnosa. Dalam penelitian

ini, ada beberapa kasus yang didahului

dengan pemeriksaan CT scan sebelumdilakukan LP Tabel 1

7 A k h d t k ik l k k ji


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7. Apakah cara dan teknik melakukan uji

diagnosa yang sedang diteliti dijelaskan,

sehingga dapat direplikasi? Ya

Dalam penelitian ini telah dijelaskan

bagaimana melakukan uji diagnosatersebut (LP) dan bagaimana

menginterpretasikan hasilnya, termasuk

dijelaskan mengenai komplikasi daritindakan uji diagnosa tersebut (LP)

8 A k h k ji di


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8. Apakah kegunaan uji diagnosa yang

sedang diteliti disebutkan?

Iya

Tujuan utama dalam penelitian ini adalah

untuk mengetahui kegunaan dan effisiensi

penggunaan lumbal pungsi di EMdepartment. Kelainan yang dapat diterapi

dapat terdeteksi, tindakan diagnostik lebih

lanjut dapat dikurangi, dan dapat menekan

biaya untuk penggunaan alat radiologi padapasien2 dengan indikasi LP.


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Conclusion of Critical Appraisal

This study was not valid enough, but it was

important and applicable


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Terimakasih....

journal lumbar punctures, nila.pptx

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