Lumbar Puncture: Lumbar Puncture: Indications and Indications and

ProcedureProcedure

Session ObjectivesSession Objectives - -Discuss the indications and contraindications for Discuss the indications and contraindications for

lumbar puncture (LP) lumbar puncture (LP) . .

- -Review the procedure of LPReview the procedure of LP..

- -Present techniques to minimize post LP Present techniques to minimize post LP headache headache . .

Indications for Lumbar Indications for Lumbar PuncturePuncture

-Diagnosis of central nervous system (CNS) infection .

-Diagnosis of subarachnoid hemorrhage (SAH) . -Evaluation and diagnosis of inflammatory CNS

processes. -Infusion of anesthetic, chemotherapy, or

contrast agents into the spinal canal . -Treatment of intracranial hypertension .

ContraindicationsContraindications - -Skin infection near site of LPSkin infection near site of LP..

- -Alteration of intracranial pressure Alteration of intracranial pressure due to cerebral mass due to cerebral mass..

- -Uncorrected coagulopathyUncorrected coagulopathy..

- -Acute spinal cord traumaAcute spinal cord trauma..

Lumbar puncture procedure

Equipment: -18G or 20G sterile spinal needle with stylet

(22G needle for children.)-Three-way stopcock.

-Manometer. Small adhesive bandage.-

-Sterile gloves for the physician. -Sterile gloves for the nurse.

-Sterile gauze pad .

-Antiseptic solution (e.g. Iodine). -25G sterile needle for injecting anesthetic.

-Three sterile collection tubes with stoppers. -Overbed table.

-3-ml syringe for local anesthetic . -Laboratory request forms and laboratory

biohazard transport bag. -Labels and light source.

-Disposable lumber puncture trays contain most of the needed sterile equipment.

Equipment: Cont.

Preparation:

1 -Determine whether written consent for the procedure has been obtained.

2 -Explain the procedure to the patient. 3 -Instruct the patient to void before the

procedure.

Performance:

1 -The patient is positioned on lateral recumbent position or sitting upright position.

2 -Small pillow may be placed under the patient's head .

3 -A pillow may be placed between the legs.4 -The patient is encouraged to relax and is

instructed to breathe normally.5 -The physician cleanses the puncture site with

an antiseptic solution and drapes the site .

TechniqueTechnique

- -Lateral Lateral Recumbent Recumbent

positionposition

Sitting uprightSitting upright

PositioningPositioning

INCORRECT CORRECT

Skin PreparationSkin Preparation - -Overlying skin Overlying skin

cleaned with cleaned with povidone-iodinepovidone-iodine..

- -Sterile drape placed Sterile drape placed with an opening over with an opening over the LSthe LS..

6 -The physician injects local anesthetic to numb the puncture site.

7 -The physician inserts a spinal needle into the subarachnoid space through the third and fourth or fourth and fifth lumber interspace.

8 -A specimen of CSF is removed and usually collected in three test tubes, labeled in order of

collection . 9 -A pressure reading may be obtained.

10 -The needle is withdrawn.

Performance: Cont.

Performance: Cont.

11 -The physician applies a small dressing to the puncture site.

12 -The tubes of CSF are sent to the laboratory immediately.

13 -Instruct the patient to lie prone for 2 to 3 hours.14 -Monitor the patient for complications of lumber

puncture.15 -Notify physician if complications occur.

16 -Encourage increased fluid intake.

17 -Documentation:

-Record the initiation and completion of the procedure.

-Patient's response. -Administration of drugs.

-Number of specimen tubes collected. -Time of transport to the laboratory.

-Specimen color, and any other characteristics.

Positioning: Key to SuccessPositioning: Key to Success - -Fetal position with neck, Fetal position with neck,

back, and limbs held in back, and limbs held in flexionflexion..

- -Lower lumbar spine Lower lumbar spine flexed with back flexed with back perfectlyperfectly perpendicular perpendicular to edge of bedto edge of bed..

- -Hips and legs should be Hips and legs should be parallel to each other parallel to each other and perpendicular to and perpendicular to tabletable..

Spinal Needle InsertionSpinal Needle Insertion -Local anesthesia

infiltrated. -20 or 22 gauge spinal

needle with stylet . -Advance spinal needle

slowly, angling slightly toward the head.

-Flat surface of bevel of needle positioned to face patient’s flanks.

Post-LP HeadachePost-LP Headache -Etiology: Prolonged leakage of

cerebrospinal fluid due to delayed closure of dural defect.

-Low CSF pressure. -Incidence 1-70%.

-Contributing factors: -Diameter of needle, shape of needle,

diagnostic vs. spinal anesthesia.

Minimizing Post-LP Minimizing Post-LP HeadacheHeadache

-Techniques:

-Needle choice.

-Number of attempts.

-Reinsertion of Stylet.

-Bed Rest after Procedure.