This podcast is 50 minutes long and I’m not sure that I gained any new insights into the procedure. However, if you have the time, give it a listen and review the procedure notes.
A number of the resources make the following points:
- Don’t do the LP if the patient is unstable.
- Don’t let getting the LP lead to a delay in starting the needed antibiotics.
- Take out the trocar as soon as you are subQ and advance without the trocar.
- Dr. Sloas of the Pediatric EM podcast recommends the infant be monitored during the procedure.
Other [perhaps more] helpful resources include:
INSPIREInfantLumbarPunctureVid eo2015Version YouTube Video from International Pediatric Simulation Society (IPSS). This brief, 8 minute, video is the best refresher of the resources on this page including the podcast.
Infant Spinal Tap Procedure YouTube Video from Dr. Larry Mellick. The ink spot on the infant’s back was made, Dr. Mellick states in the comments that follow, was made with a sterile marker contained in the LP kit.
Infant Lumbar Punctures YouTube Video from Dr. Larry Mellick.
Lumbar Puncture Instructions from the University of Florida Department of Pediatrics
Pearls & Pitfalls – How to Increase Your Success with Infant Spinal Taps, Larry Mellick, MD, MS, FAAP, FACEP
Practitioners have a love-hate relationship with this procedure. Whether you embrace it or react to its’ necessity in the same manner you would when finding out you’ve just been cut-out out of your wealthiest relative’s will, the words “lumbar puncture” invoke emotion. I would like to thank Dr. David Delemos for inventing this simple recipe for success. It is one of my favorite procedures and hopefully after hearing this podcast it will be one of yours as well.
Find the best “holder” in the department.
Should I sedate?
o Greater than 6months? Multiple previous attempts?
o Ketamine at a pain dose: 0.25-0.5mg/kg.
O2, Monitors, IV established preferred. Nothing ruins a party like trying to run a peds resuscitation without and IV.
Lateral recumbent position.
Head towards your non-dominant hand.
Use Iliac Crests to find L4-5, but choose the apex of the curve of the spine. That is the widest space.
Set up your LP tray and prep the child with solid drape in place.
Crunch again and confirm apex.
o Use the fenestrated drape to find the iliac crest and then use your non-dominant hand to find the spinous process, but then put the drape aside with the non-sterile side down on the bed just in case you may need to use it again. You will have better visualization in a blind procedure and less distractions from a moving poorly taped drape.
o Raise a nice skin wheel. The child will remember the pressure from the poke of local anesthetic when you stick again with the spinal needle, but should calm down and stop squirming when they realize there is no associated pain.
Crunch and put thumb on the spinous process above the space you plan to enter to confirm midline and enter skin 0.5-1cm below the spinous process.
o If the child is squirming then wait a few seconds for that to stop, or advance when the spinous process and the needle line-up.
Remove the trochar
o As soon as you are under the skin, remove the trochar. Then put your thumb back on the spinous process and re-determine midline and advance.
Gentle staccato advances of the needle.
o If you push in one smooth movement, you may miss the “pop” and find you have advanced to the back of the canal before the needle could fill with CSF. You will be more likely to enter the posterior vein. If you “pop” in you will be more likely to stop mid canal and drain CSF.
Band-aide and antibiotics and you are home free!
Remember frequent BREAKS decreases your risk of apnea.
When you remove the trochar to check for CSF and then want to replace the trochar to advance further: Don’t put your hand on the needle!! Put the trochar into the needle using both hands on the trochar first. Once the tip of the trochar is safely inside the needle then use your non-dominant hand to hold the needle while you advance the trochar. That way, you have no way to poke yourself while doing this procedure.