AOTW: Lumbar Punctures
Posted on: November 21, 2014, by : Jamil Madati
By Jamil Madati
Sorry for the delay in getting this out. Was busy searching for an article that would nicely summarize how the Affordable Care Act impacts us in the ED… lucky for you guys I couldn’t find one!
Instead, to dove tail into the awesome ED-HM conference this week I decided to include the following article that addresses that came up in discussion regarding the question of improving success rates of LPs.Summary of this topic (Successful LPs) can also be found on the following ACEP website link: Pearls and Pitfalls: How to Increase Your Success with Infant Spinal Taps
Title: Risk Factors for Traumatic or Unsuccessful LPs in Children
Study Design: Prospective Cohort Study over a 2yr period
Participants: Residents (Peds, EM, PEM Fellows, Pediatricians and PEM Attendings) performing LPs
Outcomes: Unsuccessful LP defined as: traumatic LP defined as > 10,000 RBC/cc or no CSF obtained on first LP attempt.
Data Analysis: Multiple logistic regression analysis to indentify the independent predictors of unsuccessful LPs. N= 1459 LPs performed, 513 (35%) of which were ‘unsuccessful’ (as defined above). Age in months of patients on which the LPs were performed on (median and IQ range): 2.8 (1.4-79.6)
Results: (Table 5 in the article) Factors associated with ‘unsusccessful’ LP
- Age < 3mo
- Difficult to visualize spine
- Difficult to palpate spine
- Less Physician experience (as defined by number of prior LPs performed)
- No local anesthetic
- Advancement of needle with stylet in place
Discussion/Conclusion:
– Authors conclude that the most ‘modifiable’ factors associated with unsuccessful LP attempts was the lack of anesthetic use and advancement of needle with stylet in place.
-In case you were wondering, in a seperate published paper in Pediatrics using the same cohort of patients, LP success rate was NOT influenced by family-member presence. Lumbar Puncture Success Rate Is Not Influenced by Family-Member Presence Nigrovic, et al. Pediatrics October 2007; 120:4 e777–e782
Karen O’Connell
Thanks Jamil for this practical article. Two of the biggest cultural changes I have experienced over the past decade have been adequate pain control, especially in infants, and allowing families to stay with their children during procedures. We have all worked very hard to overcome these particular patient care issues. It is a welcome reminder that good practice can improve outcomes for all those involved (seems logical but often overlooked).
Jim Chamberlain
I would also add that you should review this article from Dr. Mike Quinn et al.
Pediatr Emerg Care. 1993 Feb;9(1):12-4.
Pain, punctures, and pediatricians.
Quinn M1, Carraccio C, Sacchetti A.
In this study, general EM practitioners were more likely to use lidocaine for LP than pediatricians. Seems like they were ahead of us in this regard. Also, lidocaine use was associated with lower incidence of traumatic LP.
Mike, feel free to chime in.