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PORTSMOUTH HOSPITALS NHS TRUST GUIDELINE FOR ADULT LUMBAR PUNCTURE

Version 1

Name of responsible (ratifying) committee Senior Clinical Management Team

Date ratified 17 May 2017

Document Manager (job title)Consultant Nurse Emergency MedicineElderly Care SpR

Date issued 04 September 2017

Review date 03 September 2019

Electronic location Clinical Guidelines

Related Procedural Documents None

Key Words (to aid with searching) Lumbar puncture, LP, spinal tap

Version TrackingVersion Date Ratified Brief Summary of Changes Author

1 17.05.17 New guidance Phil Evans/Stephen Lester

PHT Guideline for Adult Lumbar PunctureVersion: 1Issue Date: 04 September 2017Review Date: 03 September 2019 (unless requirements change) of 17

CONTENTS

QUICK REFERENCE GUIDE................................................................................................................31. INTRODUCTION.............................................................................................................................42. PURPOSE.......................................................................................................................................43. SCOPE............................................................................................................................................44. DEFINITIONS.................................................................................................................................45. DUTIES AND RESPONSIBILITIES................................................................................................46. PROCESS.......................................................................................................................................4

6.1. INDICATIONS........................................................................................................................46.2. CONTRA-INDICATIONS........................................................................................................56.3. PROCESS (including emergency procedures)......................................................................66.4. CSF SAMPLES......................................................................................................................86.5. FAILURE TO PERFORM LUMBAR PUNCTURE..................................................................96.6. CHECKLIST FOR PROCEDURE.........................................................................................11

7. TRAINING REQUIREMENTS.......................................................................................................128. REFERENCES AND ASSOCIATED DOCUMENTATION............................................................129. EQUALITY IMPACT STATEMENT...............................................................................................1310. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS.........................................14EQUALITY IMPACT SCREENING TOOL...........................................................................................15


QUICK REFERENCE GUIDE

This policy must be followed in full when developing or reviewing and amending Trust procedural documents.

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

1. A suitably trained and skilled clinician will perform this procedure.2. This will be an aseptic procedure carried out in a clinical area. 3. This will only be performed after contra-indications have been excluded.4. It will be performed under local anaesthetic.5. This policy does not cover any aspect of intrathecal chemotherapy.


1. INTRODUCTION

Lumbar puncture is performed within the acute hospital environment in order to- obtain a sample of cerebrospinal fluid (CSF) for diagnostic purposes measure the opening pressure of the CSF for diagnostic purposes therapeutic drainage of CSF where opening pressure is raised and clinical symptoms of

raised intracranial pressure are present in accordance with the papilloedema pathway

2. PURPOSE

To ensure consistent, safe practice when performing a lumbar puncture within Portsmouth Hospitals NHS Trust.

3. SCOPE

This policy applies to all clinicians working within non specialist acute care areas within PHT. All practitioners working under this scope will be experienced clinicians. Non medical practitioners will be experienced and have appropriate post graduate education including an accredited history taking and physical examination qualifications and will be working in advanced roles.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

This policy is a guideline and there may be times when it is appropriate to deviate from any guideline based on clinical judgement with the involvement of senior members of the team.

4. DEFINITIONS

Lumbar puncture (LP) - insertion of a hollow needle into the subarachnoid space below the level of the spinal cord (L2) for diagnostic purposes

5. DUTIES AND RESPONSIBILITIES

It is the responsibility of all staff performing LPs that they are competent to perform the procedure and to adhere to these guidelines.

6. PROCESS6.1. INDICATIONS

The most common indications are:- Suspected meningitis or encephalitis- Suspected sub-arachnoid haemorrhage- Suspected idiopathic intracranial hypertension

Other investigations that may be required following specialist advice include investigations for:- CNS malignancy- CNS vasculitis- Multiple sclerosis- Guillain-Barre syndrome


Therapeutic lumbar puncture for idiopathic intracranial hypertension may be considered as per the papilloedema pathway in MAU. 6.2. CONTRA-INDICATIONS

Anti-coagulation and bleeding disorderso platelets and coagulation screen should be checked in patients if there is clinical

suspicion that they will be abnormal. Abnormal values (i.e. plts≤40, INR>1.4 or APTR>1.4) should be discussed with haematology for advice on correction prior to performing procedure

o patients taking therapeutic anti-coagulation (including NOACs) or anti-platelet medication should be discussed with a senior clinician from the requesting team as to whether LP is definitely indicated and whether haematology advice is required on reversal of anticoagulation, when it will be safe to perform LP and on any bridging anti-coagulation required

o patients receiving anti-platelet medication may need platelet transfusion and this should be discussed with the on-call haematologist before starting the procedure.

o care should be taken in relation to timing of LP to administration of anti-platelets and anti-coagulants as per the table below taken from Association of Anaesthetists national guidelines

Agent Acceptable time after drug administration for LP

Acceptable time after LP for next drug administration

UFH sc prophylaxis 4 hours 1 hourUFH iv treatment 4 hours 4 hoursLMWH sc prophylaxis 12 hours 4 hoursLMWH sc treatment 24 hours 4 hoursAspirin No additional precautionsClopidogrel 7 days 6 hoursWarfarin INR ≤ 1.4 No restrictionRivaroxaban prophylaxis 18 hours 6 hours

. Raised intra-cranial pressureo if there is any doubt as to whether intra-cranial pressure may be raised a CT

head should be performed prior to procedure but if there is no clinical suspicion of raised intra-cranial pressure, CT head is not required routinely prior to LP

o the following are clinical signs of raised intra-cranial pressure and if present CT head will be required pre-procedure:

Altered mentation

Focal neurologic signs

Papilloedema

Seizure within the previous week

Impaired cellular immunity

o the circumstances in which intra-cranial pressure is raised and it is unsafe to perform LP are presence of focal mass lesion, generalised brain swelling or blocked CSF flow. In these circumstances LPs risk precipitating tonsillar herniation and coning.

o there are instances (e.g. idiopathic intra-cranial hypertension) where there is raised intra-cranial pressure but LP is indicated. In the event of uncertainty as to whether it is safe to perform LP advice should be obtained from neurology

Infectiono localised infection of the tissue overlying the spinal cord


o epidural abscesso Meningococcal sepsis evidenced by spreading purpurao shocked patients until appropriately resuscitated o patients having active seizures until seizures controlled enough that they will not

reasonably be expected to occur during procedure

6.3. PROCESS (including emergency procedures)

Equipment

Procedure trolley Trust lumbar puncture pack which includes:

Sterile drape Gauze swabs Sterile towels 10ml syringe Green needle Orange needle Drawing up needle Manometer Small self adhesive dressing Self-adhesive numbers 1-4 for specimen bottles Paper bag (to protect xanthachromia sample from light) 4x universal specimen containers Yellow clinical waste bag Spinal needle (Whitacre type)

10mls of 1% or 2% Lidocaine (maximum dose is 3mg/ kg) ChloraPrep with tint 0.5% w/v / 70% v/v cutaneous solution Sterile gloves 1x grey glucose bottle Venesection equipment in order to take one U&E bottle immediately post LP

Care must be taken sourcing appropriate chlorhexidine spray 0.5% as stronger preparations are widely available but are contraindicated for this procedure – (N.B. some wards only stock stronger concentrations and this may well have to be sourced from another ward)

Lumbar puncture packs are stocked in MAU, D2 and F4.

Stocks of LP needles and LP packs are often not maintained reliably except in MAU and it may be worth asking in other wards if you cannot find the equipment required on your ward.

Pre-procedure

1. It is good practice for all clinicians take a brief history and physically assess the patient in order to confirm that the procedure is indicated.

a) Urgent if Suspected CNS infection Suspected SAH (>12 hours)

b) Non-urgent IIH Carcinomatous meningitis Tuberculous meningitis CNS syphilis CNS vasculitis


2. If there is clinical suspicion of raised intra-cranial pressure (see above) ensure CT Head has been performed and has a formal report. If no clinical suspicion of raised intra-cranial pressure CT is not indicated routinely. On rare occasions clinically significant raised intra-cranial pressure can be present even with a normal CT scan. Fundoscopy should thus be performed routinely as part of the pre-procedure clinical assessment.

3. Check recent blood results (U&E, LFT, FBC and clotting studies)

Ensure no contraindications (see section 6 of this document)

4. Written consent obtained through the standard PHT consent form including discussion of potential complications or consent form 4 where the patient is unable to consent for the procedure

Common risks from LP are: backache post-procedure headache transient radicular pain or paraesthesia failure of procedure

Rare but serious risks include: prolonged radicular pain or paraesthesia and paraparesis infection including meningitis and discitis spinal haematoma (can cause cauda equina syndrome) cerebral herniation abducens or other cranial nerve palsy epidermoid tumour (a late onset of tumour of the thecal sac - very rare in adults, more common in children though still rare)

Procedure

Left lateral position

This is the position of choice as it allows opening pressures to be measured. If the patient is technically challenging consider sitting them upright. Do not measure opening pressures if the procedure is performed in the upright procedure as they are not accurate and can cause confusion.

1. Lie patient on left hand side in the fetal position on bed or examination couch ensuring correct alignment of spine. Supporting the head with a pillow and putting a pillow between knees may improve position and patient comfort.

2. Expose lumbar spine and ensure patient is lying on an absorbent pad.

3. Select site for LP Identify the highest point of the iliac crests. A direct line joining these landmarks

should guide the identification of the fourth lumbar vertebral body. Identify, through palpation, the subarachnoid space at the level of L3/4 or L4/5 as

these are well below the termination of the spinal cord. Mark the identified insertion point through gentle pressure with the cap of a needle or

similar

4. Set up sterile trolley with all necessary equipment (Spinal needle, manometer, universal containers x4 lignocaine, syringes, needles, skin sterilisation fluid, sterile pack, cannula dressings and small dressing).


5. Thoroughly clean and sterilise the skin around the proposed LP site with Chlorhexidine spray and allow to dry fully.

5. Drape area accordingly

6. Using 1 or 2% Lidocaine (Lignocaine) and a 25G (orange) needle, infiltrate the skin with 1ml local anesthetic, raising a small bleb. Deeper injection can then be achieved using a 21G (green) needle, taking care to aspirate prior to injection with each movement of the needle to avoid I.V. injection. Be aware that the maximum dose is 3mg/kg and that if someone uses the maximum dose and fails the procedure, more senior clinicians and those from other specialties will be unable to make further attempts

7. The introducer should be slowly advanced angling slightly towards the head as if aiming for the umbilicus. The bevel should be positioned towards the patient’s flanks to spread rather than cut the dural sac.

8. The spinal needle should then be inserted through the introducer and gently advanced towards the dural space. It should be introduced incrementally and the stylet periodically removed to check for the presence of CSF flow. If no flow demonstrated reinsert the stylet until the subarachnoid space is entered.

9. Once CSF appears the stylet should be removed, the manometer attached and opening pressures recorded.

10. Once opening pressures established the CSF should be collected. 10-15 drops as a minimum should be collected in each sequentially numbered universal containers and then the Glucose bottle. The safe maximum volume that can be collected is 40mls though larger volumes may increase the risk of post procedure headache.

11. If performing therapeutic drainage of CSF for IIH ensure closing pressure is checked and documented in discharge paperwork along with opening pressure (this is helpful for tertiary follow up.)

12. Once the samples have been collected the manometer should be removed and the stylet reinserted. The spinal needle can be gently removed until it is within the body of the stylet and then both stylet and needle can be removed together.

13. The insertion site should be covered with a dressing.

14. Immediately after the procedure venesection should be performed and paired serum samples should be sent for glucose, protein and, if CSF xanthachromia requested, bilirubin. Delay in doing this can prevent meaningful interpretation of CSF glucose.

6.4. CSF SAMPLES

It is the responsibility of the clinician on the requesting team to ensure that CSF is delivered to the biochemistry and microbiology laboratories and that the laboratories are made aware that the sample of CSF will be arriving. Unfortunately, if this is not done there is potential for delay in analysis and the sample may degrade prior to analysis preventing tests such as cell counts. Biochemistry can be contacted on extension 6348 and microbiology on 1720. The laboratories are found on E-level in the pathology block (near wards E1-4.) Out-of-hours, the on-call microbiology technician may not be in the laboratory but can be bleeped through switchboard.

For audit purposes and to ensure the correct tests are performed it is recommended to request the investigations required on the CSF on ICE pre-procedure rather than by handwritten request.


As a minimum for each LP, CSF should be sent for cell count, microscopy and culture, total protein and glucose. A paired blood sample for plasma glucose, total protein and bilirubin (if xanthachromia requested) needs to be sent immediately post-procedure.

Bottles 1 and 3 should be sent to microbiology for cell count and microscopy and culture, viral PCR is commonly required and can be performed on these bottles too if requested. 1ml CSF is sufficient for routine culture and standard viral PCR (i.e. HSV /enterovirus). Please note any additional test requires +/- 200-300ul each on top of this amount; up to 5ml is needed for TB culture. Numbering the tests required in order of importance (in case a broad range of differential diagnosis is considered) will help processing the sample without delays and unnecessary wastage.

Bottles 2 and 4 as well as the grey top glucose should be sent to biochemistry for glucose and protein (and xanthachromia if indicated)

It is recommended to send an additional 'spare' bottle of CSF in case of requiring further tests post-procedure

Xanthachromia is indicated for suspected SAH. This is sensitive to light so ensure that it is protected from excess light exposure by using the bag in the LP pack. The laboratory in QAH can now process xanthochromia requests out of hours as of February 2017.

To avoid unnecessary repeated LPs, where the clinician is unfamiliar with a test being performed, it would be wise to check with the neurology team and the laboratory how much CSF they require and if there are any special requirements for the sample (e.g. flow cytometry can only be performed with prior agreement of the laboratory and needs to be done early in the day) before performing the procedure and sending the sample.

Cytology (including flow cytometry) requires a sample of at least 5ml CSF.

CSF testing for oligoclonal bands can be very useful in inflammatory conditions and a paired serum sample is required with this.

When considering any less common microbiology cause, it is worth sending a serum save (red-topped silicone coated tube) in case CSF PCR is negative.

If the procedure was particularly challenging or has been repeated for further investigations it may be worth communicating with the laboratories the order of priority of the investigations in case there is inadequate sample for all of the requested investigations.

6.5. FAILURE TO PERFORM LUMBAR PUNCTURE

If the lumbar puncture proves technically challenging, multiple attempts should not be made by junior members of the team and the procedure should be attempted by the most senior, available clinician from the requesting team. If the procedure still cannot be performed support can be sought from the on-call anaesthetists (bleep 1622) or from interventional radiology (opposite RAU).

Prior to seeking support from anaesthetics or radiology, the requesting team must ensure that their consultant feels the procedure is necessary, the patient is adequately consented, and that all of the necessary equipment and completed request forms are brought with the patient. If it has not already been sought, it might be prudent to consider neurology input at this stage as to whether any unusual tests would be helpful because it will be more difficult than usual to repeat the procedure at a later date if further investigations are required.


It remains the responsibility of the operator performing the procedure to ensure that samples are appropriately labelled and conveyed to the laboratory. Clinical teams will be expected to support this procedure except in extreme circumstances or when the clinician performing the procedure feels this unnecessary.


6.6. CHECKLIST FOR PROCEDURE

No

Yes

No

Yes

Yes

No


LP indicated?

Clotting, anticoagulation and antiplatelet

safe?

Evidence of raised ICP?

Gain written consent

Inform biochemistry and microbiology laboratories to expect sample of CSF

Request required CSF investigations on ICE

Gather necessary equipment (see section 7 for more detail)

Perform LP

Take paired serum samples and take these and CSF to the laboratory

Document procedure in patient notes including results and ensure any

outstanding results are reviewed ASAP by the on-call team

Review indications (Section 5) and do not perform LP unless

indicated

Reverse anticoagulation if safe to do so. Seek

haematology advice if required. Delay LP until

clotting is safe

It may still be safe to perform LP (see Section 6) but if in any doubt seek neurology advice before performing LP

7.8. TRAINING REQUIREMENTS

It is highly recommended that before performing this procedure the clinician observe at least two LPs performed by a suitably skilled and experienced practitioner.

Lumbar puncture should only be performed by a clinician who is competent to perform the procedure unsupervised. Clinicians should have a directly observed procedure (DOPS) on their portfolio to provide evidence of this. Where a competent clinician is happy to supervise a clinician who is not yet able to perform lumbar puncture independently the supervising clinician will bear responsibility for ensuring the procedure is performed correctly.

For the non-medical workforce a Consultant or registrar with appropriate, current competence in performing lumbar punctures will provide clinical supervision discussing at minimum; consent, preparation, local anesthesia, site selection, sampling and post procedure care. Competence will be assessed in the same way as the medical trainee in the form of a summative DOPS by appropriately skilled practitioner. A procedure log is mandatory for the non-medical workforce in order to demonstrate ongoing experience and maintenance of competence.

9. REFERENCES AND ASSOCIATED DOCUMENTATIONDeible, M. (2004) Reinsertion of the stylet prior to needle removal in diagnostic lumbar puncture. BestBETs Best Evidence Topics. Available at: http://bestbets.org/bets/bet.php?id=776 [Accessed: 16/10/15]

Johnson, K.S. and Sexton, D.J. (2013) Lumbar Puncture: Technique, indications, contraindications and complications in adults. Up to Date available at: http://www.uptodate.com/contents/lumbar-puncture-technique-indications-contraindications-and-complications-in-adults?source=search_result&search=lumbar+puncture&selectedTitle=1%7E150#H1[Accessed 16/10/15]

Wright, B.L.C., Lai, J.T.F and Sinclair, A.J. (2012) Cerebrospinal fluid and lumbar puncture: a practical review. Journal of Neurology. 259: 1530-1545

W. Harrop-Griffiths, T. Cook, H. Gill, D. Hill et al. (2013) Regional anaesthesia and patients withabnormalities of coagulation. The Association of Anaesthetists of Great Britain & Ireland, The Obstetric Anaesthetists Association, Regional Anaesthesia UK. Available at: https://www.aagbi.org/sites/default/files/rapac_2013_web.pdf[Accessed 23/5/17]


https://www.aagbi.org/sites/default/files/rapac_2013_web.pdf

http://www.uptodate.com/contents/lumbar-puncture-technique-indications-contraindications-and-complications-in-adults?source=search_result&search=lumbar+puncture&selectedTitle=1~150#H1



http://bestbets.org/bets/bet.php?id=776

http://bestbets.org/bets/bet.php?id=776

10. EQUALITY IMPACT STATEMENTPortsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Respect and dignityQuality of careWorking togetherEfficiency

This policy should be read and implemented with the Trust Values in mind at all times.


11. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

Minimum requirement to be

monitored

Lead Tool Frequency of Report of Compliance

Reporting arrangements Lead(s) for acting on Recommendations

Audit awareness of the guideline

Consultant Nurse, AMU

Audit 6-month post introduction of guideline

Policy audit report to:

SCMT



This document will be monitored to ensure it is effective and to assurance compliance.


EQUALITY IMPACT SCREENING TOOLTo be completed and attached to any procedural document when submitted to the

appropriate committee for consideration and approval for service and policy changes/amendments

Stage 1 - Screening

Title of Procedural Document: PHT Guideline for Adult Lumbar Puncture

Date of Assessment 25 July 2017 Responsible Department

MOPRS

Name of person completing assessment

Stephen Lester Job Title SpR

Does the policy/function affect one group less or more favourably than another on the basis of :

Yes/No Comments

Age No

DisabilityLearning disability; physical disability; sensory impairment and/or mental health problems e.g. dementia

Ethnic Origin (including gypsies and travellers) No

Gender reassignment No

Pregnancy or Maternity No

Race No

Sex No

Religion and Belief No

Sexual Orientation No

If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2

More Information can be found be following the link below

www.legislation.gov.uk/ukpga/2010/15/contents

Stage 2 – Full Impact Assessment


http://www.legislation.gov.uk/ukpga/2010/15/contents

What is the impact Level of Impact

Mitigating Actions(what needs to be done to minimise /

remove the impact)

Responsible Officer

Monitoring of Actions

The monitoring of actions to mitigate any impact will be undertaken at the appropriate level

Specialty Procedural Document: Specialty Governance CommitteeClinical Service Centre Procedural Document: Clinical Service Centre Governance CommitteeCorporate Procedural Document: Relevant Corporate Committee

All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee
