Paediatric Lumber Puncture

Indications in ED

• As part of the septic screen of a neonate
• As part of the septic screen of an infant or child where there are concerns for meningitis

Note- there are many other indications for paediatric lumbar punctures, but these are often performed on the ward by inpatient teams or after neuroimaging.

Contraindications

• Reduced GCS
• Signs of raised ICP, such as: altered pupil responses, bulging fontanelle, posturing.
• New focal neurological signs, such as: hemiparesis, ocular palsies
• Local infection at the needle insertion site
• Known coagulation defects or thrombocytopaenia
• Cardiovascular compromise/shock
• Respiratory compromise, such as apnoeas.

Equipment

• Dressing trolley
• Sterile: gown, gloves, mask, hat, hand towel, drape
• Large dressing pack
• Skin antiseptic
• o Infants, children, adolescents: chlorhexidine 2% & isopropyl alcohol 70% (e.g. Maxi swabstick) or

o  Povidone iodine 10% if known sensitivity to chlorhexidine

o  Neonates ≥ 28 weeks gestation: chlorhexidine 1% & isopropyl alcohol 70% (swab stick preferable)

• Spinal lumber puncture needle- 22G or 25G bevelled needles with stylet (the use of needles without a stylet has an associated rare risk of spinal epidermoid tumours)

o  Pencil point is preferred in older children to reduce risk of headache (evidence is not convincing in younger children)

• Topical anaesthetic cream
• Local anaesthetic with syringe and needle
• Sucrose
• Manometer set
• 3 sterile CSF specimen containers
• Small transparent occlusive dressing

Prior to procedure

• Apply local anaesthetic cream to the back if time allows
• Ensure child is on continuous pulse oximetry/HR monitoring and consider cardiac monitoring where appropriate
• Ensure enough staff present for procedure. Often need

o  Proceduralist

o  Assistant to pass specimen tubes and to monitor observations

o  Assistant to hold the baby

o  May even need a 3rd assistant if sedation (such as sucrose) required

Procedure

• Perform hand hygiene
• Open sterile equipment onto sterile field trolley
• Assistant to position the patient

o  Position the patient in a lateral position with the patient facing the positioning nurse

o  Patient knees and chin are to be drawn to the chest, and body well flexed (foetal position)

o  The hips should be vertical to align the iliac crests i.e. back should be 90 degrees to the bed

o  The patients back should be positioned parallel and close to the edge of the bed.

• Identify the LP site

o  A line between the top of the iliac crest intersects the spine at approximately the L3/L4 interspace:

o  Site for needle insertion should be L3/L4 or L4/L5 interspace.

• Apply mask. Perform aseptic hand wash and apply gown and gloves
• Clean skin with antiseptic swab sticks

o  Wipe antiseptic swab in a circular motion commencing at the proposed insertion site

o  Repeat with second swab stick or sterile forceps and gauze

• Place drape onto patient
• Palpate the needle insertion point
• If using local anaesthetic then infiltrate this into the site and allow 1-2 minutes for it to work
• Ensure the skin is dry prior to needle insertion
• Perform the LP

o  Hold the spinal needle so that bevel is in the superior position (facing up)

o  With the stylet in position, insert the needle through the skin and wait for any patient movement to stop

o  Aiming for the umbilicus, advance the needle in the direction towards patient’s umbilicus until there is a decrease in resistance.

o  Remove the stylet and check for CSF appearing at the needle hub:

• If CSF is not flowing: Replace stylet fully and advance or reposition the needle slightly and recheck for CSF as above.
• If CSF is flowing
• If opening pressure measurement is required, connect manometer to spinal needle.
• Collect 10 drops in each (x3) sterile container

o  Pass them to the assistant who can label them 1-3 in order of collection and label them with the patient details

• When sample collection is complete, reinsert the stylet, then remove the needle and stylet as one
• Use sterile gauze to apply gentle pressure to the insertion site
• Cover the insertion site with a transparent occlusive dressing

Post Procedure

• A minimum of hourly neurological observations for 4 hours for all patients post procedure (may require longer depending on underlying illness).
• Patients should be allowed to mobilise as soon as it is safe to do so and, if applicable, on recovering from sedating medication.

Complications

• Headaches (common, up to 15%)
• Local back pain
• Transient / persistent paraesthesia / numbness
• Cerebral herniation ( bradycardia, apnoeas, oxygen desaturations)
• Subdural haemorrhage
• Spinal epidural haemorrhage
• Paraplegia
• Infection (local and introduction into CSF spaces)
• Cardiorespiratory compromise due to positioning
• Spinal epidermoid tumours associated with needles without a stylet (rare)