Positioning for Lumbar Puncture
I am likely jinxing myself (and anyone working in the Peds ED while reading this… sorry), but it is useful (at least I think so).
Just close your eyes and imagine that it is 0530hrs and a 3 week old pops up on the board with the word “Fever” in the complaint column. You “spring” into action: H+P, Labs ordered, Abx ordered, and bed requested. Then you look around and find the “best holder,” because we all know that these little ones squirm.
The kid appears well enough, except for the copious snot flowing from the nares… making you glad not to be near the face during the procedure. The master holder takes the child and “crunches” them into a near circle (head nearly touching toes). You begin your procedure to the tunes of gurgling snot and a perfectly still patient. Sounds customary… but should it be?
A few points on LPs:
Place the child (especially a neonate) on a monitor or at least a PulseOx.
- Recall that the airway of the very young can be easily occluded by simple positions, like being forced into the shape of a donut.
- Many of these neonates will have copious snot in nares, that alone can cause them trouble.
- A successful LP deserves commendations, but no rewards are given if you then have to resuscitate the patient.
Make your first attempt your best attempt.
- Double-check your positioning twice or thrice before inserting needles.
- Consider Oral Sucrose and LMX on the back to help decrease the squirming.
Do NOT flex the neck. (what?)
- Recent study using ultrasound to measure the interspinous space demonstrated that neck flexion does not increase the interspinous space.
- The U/S study also showed that the largest interspinous space was achieved in the upright, hips flexed position (ie. leaning forward).
- Not all patients can be done in the upright position (if you need opening pressure for instance), but in either position, hip flexion improved the size of the space and neck flexion did not.
— Abo, Alyssa, Chen, Lei, Johnston, Patrick, Santucci, Karen. Positioning for Lumbar Puncture in Children Evaluated by Bedside Ultrasound. Pediatrics 2010 125: e1149-e1153