Transcript Slide 1

Research Study
Case-Series Analysis of Risk Factors for
Unsuccessful Lumbar Punctures In Patients Less
Than 90 days Old in Riverside County Medical
Center (RCRMC) in 2007
INVESTIGATORS:
Soheil Samvatian PGYIIIFM
Maisara Rahman PGYIIIFM
BACKROUND
Lumbar puncture is a procedure that is very
commonly performed in children.
Unsuccessful Lumbar Punctures can cause
substantial diagnostic uncertainty and may lead
to unnecessary antibiotic use and
hospitalization.
OBJECTIVE:
1. To Identify Risk Factors For
bloody/Unsuccessful Lumbar Punctures
2. To identify if procedural factors like the
use local anesthetic helps in preventing
bloody/Unsuccessful Lumbar puncture
3. Analytic reason for Lumbar puncture
practically obtained in the Hospital
Hypothesis:
Based on the retrospective analysis of
40 charts of performed LP at RCRMC
We will identify modifiable procedural
factors that are associated with
bloody/unsuccessful Lumbar punctures
that can be improved
Methods:
 Retrospective studies of case records,
performed lumbar punctures in RCRMC in
patients younger than 3 months old
Charts reviewed from Jan-Dec 2007
Patients less than 3 months old qualified
40 charts were reviewed
40 Charts:
8 Patients in NICU
32 Patients in pediatric floor
Methods Cont..
 Data collection ( Chart Review Grid)
 Gender
 Age
 Reason for spinal tap
 Birth History
 Medication
 CRP,CSF culture,Blood culture,DAT,CSF
analysis,
 Other studies,final diagnosis
 Hospitalization duration
Methods Cont..
BloodyTap defined as, RBC > 500
Unsuccessful Taps: Lumbar Puncture
performed which CSF was sent for limited
evaluation,
Dry Tap :no CSF was drawn
Data Analysis:
 Gender
(43%)17 cases->female
(57%)23 case ->male
male
female
Gestational Age
AGA,30 newborns
SGA ,4 newborns
LGA,2 newborns
2 cases unknown
6 cases preterm reported (GA<37 weeks)
No post-term reported
Birth History
 NSVD (Normal Spontaneous Vaginal
Delivery),31 cases
. GBS positive,2cases,treated at least two times
. GBS unknown,14 cases,
. GBS negative,15 cases
 Vacuum extractor ,one case with GBS positive ,treated two
times in delivery
 Cesarean Section ,8 cases
 Another co-morbidity ,GDM diet controlled(A1)3 cases,
Galactosemia one case, maternal substance abuse two cases, maternal
syphilis2cases,hypothyroidism/depression one case
Frequency polygons of LP distributed in
age
(No. of LP/Days)
7
6
5
4
3
No.
of
LP
2
1
74
45
37
27
21
18
10
3
1
0
Reasons for Lumbar puncture
25
20
15
10
FEVER &GI
ALTE
FEVER
SEIZURE
POOR FEEDING
RESPIRATORY
0
SYPHILIS
5
Fig.3
FEVER &GI
ALTE
FEVER
SEIZURE
POOR FEEDING
RESPIRATORY
SYPHILIS
Reason for LP
Fever,25 cases
Fever with GI symptoms,7 cases
ALTE/gasping/apnea,6 cases
Rule out congenital syphilis,2 cases
Rule out Seizures ,5 cases
Respiratory symptoms,3 cases
Poor feeding /GI symptoms,3 cases
Histogram of the causes
0.35
seizures
0.3
PNA/RDS
Fever unknown
source
ALTE unknown
0.25
0.2
0.15
Poor feeding
0.1
V meningitis
Bactremia/sepsis
0.05
conj.syphilis
0
causes
Fig. 5
UTI
conj Abn
GERD
Hospitalization
 Admission between 2 days to 142 days!
 47% patients discharged after 3 days
 2cases hospitalized more than 2 weeks because of
other co-morbidities
 One case LP failed antiviral with antibiotic given for
complete course(14 days)
Images and studies:
 Chest X-Ray 24 cases
 Head MRI 7 cases
 Head CT without contrast 6 cases(4 cases
before LP taken)
 Head U/S 1 case
 EEG 8 cases
 Kidney U/S 5 cases
 VCUG 3cases inpatient 2 cases outpatient
 Echo-cardiogram 2 cases
 UGI fluoroscopy 1 case
C reactive protein (CRP)
In 20 cases measured, which in 8 patients
CRP level were more than one
One patient rule out congenital syphilis ,
One case seizure,
One case Urinary Tract Infection (UTI)
One case pneumonia
4 cases fever with unknown source
C Reactive Protein cont.
12 cases CRP <1
One case Enterovirus Meningitis,
One case with Bactremia ,
One case with rule out seizure,
Nine cases with unknown/nonspecific
fever
Cont C reactive protein
20 cases
CRP
Initially ordered
8 cases CRP>1
12 cases CPR <1
1 case PNA
1 case UTI
1 case sz
1 case
enterovirus meningitis
1case sz
4 cases
unknown fever
9 cases
unknown fever
1 case bactremia
R/O congenital syphilis
Cerebrospinal fluid results
 3 cases cerebrospinal fluid culture were positive
 Direct Antigen Test (latex test) for 21 patients
ordered which were negative
 Lumbar puncture for 15 cases attempted limited
CSF
 10 cases bloody ,which 7case> 10.000 RBC and
2cases >500 RBC
 13 cases Lumbar puncture were completely
successful
 2 cases was dry tap
retrospective study of children<90 days
undergoing LP in RCRMC in 2007
40 LPs
enrolled
(2)5%drytap
(13)32%LPsCSF
RBC<500
(10)25%LPsCSF
RBC>500
17%CSF RBC>10.000
(7)
(15)37%
Limited CSF sample
for culture
7%CSF RBC<10000
(3)
Prospective cohort of children undergoing
LP in Nigrovic & Neurman study(2003-2005)
1459 LPs
Enrolled
875(60%)LPs
With CSF<500
71(5%)LPs with CSF
21(1%)LPsCSF
>500
>10.000on first attempt
321(22%)LPs with
RBC<10000
432(34%)LPs
Unsuccessful
On 1st attempt
85(6%)LPs RBC>
10000
86(6%)unsuccessful
Cont, retrospective study
Among 40 cases were performed by
 Attending 20 cases
 PGYI
3 cases
 PGYII
5 cases
 PGYIII 12 cases
Location of procedure
Pediatric floor
NICU
ER
PICU
15
8
15
2
cases
cases
cases
cases
Types of anesthesia
Local injection lidocaine 1% 6 cases
EMLA
7 cases
Versed conscious sedation one case
No anesthesia
26cases
Successful ratio based on anesthesia
26% no anesthesia
57% EMLA
50% local injection lidocaine
Successful ratio based on physician’s
factor
45%
50%
0%
0%
Attending
PGYIII
PGYII
PGYI
Frequency Polygon of Unsuccessful LP in age
distribution ( Number of LP/Days )
8
7
6
5
unsuccessful
LP
4
3
2
1
80
65
50
35
20
5
0
Basics in Lumbar Puncture
Position
Prep/drape
Infiltrative anesthetics or topical
anesthetics
Technique
Lateral recumbent
 The lateral recumbent position is used most
frequently. The child is positioned near the edge
of the examining table. The child should have
the neck flexed and knees drawn upward by the
assistant
 the assistant places one arm around the
posterior aspect of the child's neck and the other
arm under the child's knees
 The child's hips and shoulders should be kept
perpendicular to the examining table in order to
maintain spinal alignment without rotation.
Lateral recumbent position
Sitting position
 The sitting position may be preferred in children
who have the potential for developing respiratory
compromise because of hyper flexion of the
neck in the lateral recumbent position
 In addition, this position may improve flow of
CSF in very small infants (less than two weeks
of age).
 The assistant grasps one of the infant's arms
and one of the legs in each hand while
supporting the head to prevent excessive flexion
at the neck.
Sitting position
Position in this Research
Only one case sitting position performed
(by PGYIII )
Fetal position (Lateral recumbent position)
were reported for the rest of cases
Technique
 After Sterile preparation, The spinal needle is
checked to ensure that the stylet is firmly in
place
 The spinal needle is positioned in the midline
with the bevel parallel (facing up) to the direction
of the fibers of the ligamentum flavum
 This positioning of the needle is thought to
decrease CSF leak after the procedure is
completed because the needle separates, rather
than cuts, the fibers of the dura
Cont. Technique
 The needle is advanced slowly through the spinous
ligaments aiming slightly cephalad toward the umbilicus
 A "pop" often is perceived as the needle penetrates the
dura and enters the subarachnoid space. At this point,
the stylet can be removed.
 Since penetration of the dura is not always obvious and
the depth to which the needle must be inserted varies
depending on the size of the patient and body habitus,
the stylet can be cautiously removed from time to time as
the needle is advanced to look for CSF
Use of manometer
 Opening pressure measurement may be
deferred in a struggling or uncooperative patient,
or if the LP is performed with the patient in the
sitting position, because the measurement may
be unreliable
 Normal opening pressures range from 50 to 200
mm H2O in a relaxed patient in the lateral
recumbent position with the neck and legs
extended. The range can increase to 100 to 280
mm H2O in patients in the lateral recumbent
position with the neck and legs flexed
Manometery
Fluid collection
 The CSF should be collected in three to four
sterile tubes. Approximately 1 mL
 The first tube should be sent for Gram stain and
bacterial culture and antigen detection, the
second for CSF glucose and protein, and the
third for CSF cell count and differential
 Additional tubes may be saved for future studies
or used for viral culture, fungal culture, cell
pathology, or special chemistries
 If subarachnoid hemorrhage (SAH) is suspected,
four tubes should be collected
Rapid Diagnostic Test
Antigen detection by latex particle
agglutination was once a routine part of
bacterial meningitis
This test can be still useful because Gram
stained smear or culture may be negative
in pretreated patients
This test has high sensitivity but has low
specificity
CT should be performed before LP
Altered mental status
 Focal neurological signs
 Papilledema
Seizure
Risk for brain abscess
(immunocompromise or congenital heart
disease with a right-to-left shunt)
Specific contraindications
 Increased intracranial pressure (ICP)
 Bleeding diathesis — Evidence regarding the safety of
performing LP in patients with thrombocytopenia or
coagulation factor deficiency is limited, Nevertheless,
because of the risk of subdural or epidural hematoma
formation, it generally is not advised performing LP in
patients with coagulation defects who are actively
bleeding, have severe thrombocytopenia (eg, platelet
counts <50,000/microL), or an INR >1.4
 Cardiopulmonary instability
 Soft tissue infection at the puncture site
What if!
 Patients with spinal abnormalities (such as spina
bifida or severe scoliosis) should be identified.
An alternative approach for obtaining CSF (such
as performing the procedure under fluoroscopy)
may be required for such patients
 In Poor flow , Pulling the needle back to the
subcutaneous tissue and redirecting
 Removing the spinal needle and attempting the
procedure at a different site; a new needle
should be used for each additional attempt, if the
needle has been removed completely
Bloody puncture
 A traumatic puncture occurs when the spinal
needle strikes the venous plexus that encircles
the spinal cord
 The CSF typically clears as it is collected if the
spinal needle is in the subarachnoid space
 The spinal needle should be removed if the
bloody fluid clots in the hub or does not clear
 Predicted CSF WBC count/microL = CSF RBC
count x peripheral blood WBC count /peripheral
blood RBC count
Bloody puncture Cont,
The presence of CSF bleeding results in
approximately 1 mg of protein/dL per 1000
RBCs/microL
 The CSF-to-serum glucose ratio is
approximately 0.6 in normal individuals;
In traumatized one ,glucose falsely going
up
Characteristic of Cerebrospinal fluid
 Successful lumbar puncture estimated
Neonate
 WBC 6(3-10),
 RBC1(0-3),
 Protein 144(54-234),
 Glucose44(38-56),
Infant
 WBC8(5-12)
 RBC 0,
 Protein94(68-121),
 Glucose48(42-55)
Cerebrospinal fluid results cont,
 7 cases local anesthesia recorded (EMLA cream
applied) Eutectic Mixture of Local Anesthetic
 Among 7 patients with local anesthesia
applied,4 cases were successful and 2 cases
CSF RBC >500 and one case limited.
 Oral sucrose (sweet ease) given to patients
reported( 2 cases ) which both with EMLA was
successful LP
Anesthetics
Local anesthesia should be provided
whenever possible when performing
lumbar puncture (LP) in infants
 Available options include infiltration with
lidocaine and/or topical preparations (such
as EMLA or LMX-4)
Oral sucrose offered to infants on a
pacifier is safe and effective when used to
reduce procedural pain for single events
What is local Anesthesia
 EMLA cream, One of the first and most studied
topical creams is a eutectic mixture of local
anesthetics, a prilocaine 2.5% and lidocaine
2.5% cream. When applied for a minimum of 45
to 60 minutes, extensive evidence supports
reduction of pain from IV catheter insertion. In
contrast to the other tropical's, EMLA can be left
on up to 4 hours, and its duration of action
continues an hour after removal. In addition,
depth of anesthesia increases up to 6 mm
during prolonged application

Side Effect
Methemoglobinemia is rare side effect
more likely in preterm infants lacking the
enzyme to reduce it. Current
recommendations limit EMLA to neonates
at least 37 weeks gestational age
Allergic reaction urticaria , angioedema ,
bronchospasm ,shock rarely reported
EMLA Application Dosage and Time
0 up to 3 months or < 5 kg 1 g 10 cm2 1
hour
3 up to 12 months and > 5 kg 2 g 20 cm2
4 hours
1 to 6 years and > 10 kg 10 g 100 cm2 4
hours
7 to 12 years and > 20 kg 20 g 200 cm2 4
hours
What about another studies:
 Among 297 infants ≤ 3 months of age receiving lumbar
punctures in an emergency department, LPs performed
with a local anesthetic were twice as likely to be
successful as those performed without local anesthesia
(OR: 2.2, 95% CI 1.04-4.6)
 In a prospective series describing 1459 children
receiving lumbar punctures in an emergency
department, procedures performed without local
anesthetic were more likely to be traumatic or
unsuccessful than those performed with local anesthesia
(OR: 1.6, 95% CI 1.1-2.2)
 Eventually ,observational evidence suggests that using
a local anesthetic increases the likelihood of a
successful procedure
Bottom-line
Chart audits can be useful tools in
improvement and safety efforts
Of the factors associated with bloody or
unsuccessful lumbar punctures in children,
lack of local anesthetic use seems to be
modifiable
references
 Up To Date, Lumbar puncture: Indications, contraindications,
technique, and complications in children, Last literature review version
16.2: May 2008
 Division of Emergency Medicine ,Children’s Hospital and Harvard
Medical school, Risk Factor Traumatic or Unsuccessful Lumbar
Punctures in Children ,Volume 49,No.6,June 2007
 American Academy of Pediatrics(AAP)Department of Pediatrics,
Epidemiology and biometry Core, Local Anesthetic and Stylet
Atyles:Factors associated with resident Lumbar Puncture Success,
Pediatrics Volume 117,Number 3 ,March 2006
 eMedicine-Methemoglubolinemia Article Last Updated: Apr 5, 2007