Lumbar Puncture

1st Year MSc Nursing
Medical Surgical Nursing
MIMS CON

1. LUMBAR PUNCTURE Prepared by Ms.Theertha P Krishna 1 st Year MSc Nursing MIMS CON

2. INTRODUCTION A Lumbar puncture (or LP, and known as a spinal tap) is a diagnostic and at times therapeutic medical procedure. Diagnostically it is used to collect cerebrospinal fluid (CSF) to confirm or exclude conditions such as meningitis and subarachnoid hemorrhage and it may be used in diagnosis of other conditions.

3. DEFINITION A Lumbar Puncture is the insertion of a needle into the lumbar region of the spine in such a manner that the needle enters the lumbar arachanoid space of the spinal canal below the level of the spinal cord so that the cerebrospinal fluid can be withdrawn or a substance can be therapeutically or diagnostically injected.

4. INDICATION Lumbar puncture may be done to : Collect cerebrospinal fluid for laboratory analysis. Measure the pressure of your cerebrospinal fluid Inject spinal anesthetics, chemotherapy drugs or other medications Inject dye ( myelography ) or radioactive substances into cerebrospinal fluid to make diagnostic images of the fluid's flow.

5. 2.To obtain CSF for the diagnosis of: Meningitis Meningo encephalitis Subarachnoid hemorrhage Malignancy – diagnosis and treatment

6. CONTRAINDICATION Idiopathic or Suspicion of increased ICP cerebral mass. Bleeding diathesis Skin infection Abnormal respiratory pattern Hypertension with bradycardia and deteriorating consciousness.

7. Obtunded state with poor peripheral perfusion or hypotension. Seizures-prolonged or recent (within 30 minutes) Inexperienced physician Vertebral deformities (scoliosis or kyphosis ) Acute spinal trauma.

8. WHERE TO INSERT THE NEEDLE ??

9. WHERE TO INSERT THE NEEDLE ?? The imaginary line that crosses the lumbar region of the back joining the posterior superior iliac crests will cross the L3-L4 interspace

10. EQUIPMENTS A spinal or lumbar puncture tray should include the following items: Sterile dressing Sterile gloves Sterile drape Antiseptic solution with skin swabs Lidocaine 1% without epinephrine Syringe, 3 mL Needles, 20 and 25 gauge

11. Spinal needles, 20 and 22 gauge Three-way stopcock Manometer Four plastic test tubes, numbered 1- 4, with caps Syringe, 10 mL (optional).

12. NEEDLE GAUGES

13. PROCEDURE Assess the general condition of the patient and check all the laboratory investigations. Preapare all the articles. Wash hands Wear the gloves and maintain sterile field. Performed with the patient in the lateral recumbent position. Spinal needles entering the subarachnoid space at this point are well below the termination of the spinal cord.

14. Apply topical anesthetic 30-45 min prior to procedure. Spinal cord ends at L1-L2, so sites for puncture are located at L3-L4 or L4-L5. Restrain patient in lateral decubitus position. Maximally flex spine without compromising airway. Keep alignment of feet, knees and hips. Position head to left if right handed or vice versa. Cleanse skin with povidone iodine from puncture site radially out to 10 cm and ALLOW TO DRY

15. Drape below patient and around site with fenestrated drape. Anesthetize with lidocaine if topical not used by: Intradermally raising a wheal at needle insertion site. Advance needle through wheal to desired interspace . Insert spinal needle with stylet with bevel up to keep cutting edge parallel with nerve and ligament fibers.

16. Hold needle firmly A “pop” of sudden decrease in resistance indicates that ligamentum flavum and dura are punctured. Remove stylet and check for flow of spinal fluid. If no fluid, then: Rotate needle 90°. Reinsert stylet and advance needle slowly checking frequently for CSF.

17. If bony resistance is felt deeply, then withdraw needle to the skin surface and redirect more cephalad and increase patient flexion. If bloody fluid that does not clear or that clots results, then withdraw needle and reattempt at a different interspace .

18. When CSF flows, attach manometer to obtain opening pressure if desired. Pressure can only be accurately measured in lateral decubitus position and in the relaxed patient. Attach manometer with a 3-way stopcock when freeflow of CSF is obtained. Read column when highest level is achieved and respiratory variation is noted

19. Collect 1ml of CSF in each of 3 vials for: Tube 1: culture & gram stain Tube 2: glucose, protein Tube 3: cell count & differential and extra CSF if desired for other lab tests Check closing pressure with manometer, if desired. Reinsert stylet and remove needle in one quick motion Cleanse back and cover puncture site

20. SITTING POSITION Restrain infant in the seated position with maximal spinal flexion. Hold infant’s hands between flexed legs with one hand and flex head with the other hand. Drape patient below buttocks and fenestrated drape opening over puncture site. Insert needle so bevel is parallel to spinal cord (Bevel left or right). Cannot measure pressure accurately in this position.

21. AFTER CARE Once the needle is removed, a small bandage is placed over the hole in your skin and you will be asked to remain flat on the exam table for a minimum of 30 minutes to help prevent any leakage of spinal fluid after the procedure. You will be encouraged to drink extra fluid while you recover and for the next two to three days.

22. A headache following spinal tap occurs in up to 20 percent of patients. It typically occurs upon standing and is relieved by lying down. You should lie flat on your back or stomach (but not your side) for as long as you can the first 24 hours after the procedure or if you have a headache. Also, to minimize complications, it is recommended that patients avoid bending and heavy lifting for two to three days following the procedure.

23. Even lifting a small child following this procedure can cause the clot formation to become dislodged, resulting in a headache. Your provider will tell you when it is safe to return to work. Most people can generally return to work in one to two days. Wash hands. Recording and reporting.

24. COMPLICATIONS Headache Apnea (central or obstructive) Back pain Bleeding or fluid leak around spinal cord Infection, pain, hematoma Subarachnoid epidermal cyst Ocular muscle palsy (transient) Nerve Trauma