Lumbar Puncture Part 2: Pearls, Pitfalls, and Troubleshooting

a monthly blog series on procedures


Take your LP skills to Eleven: this is spinal tap!

Last week we discussed the basics of the adult LP. This week we will guide you through some difficult scenarios and their solutions.

THE SPOOKED PATIENT

troubleshootingYour patient is nervous and squirmy

  • Consider having an assistant hold and position the patient.
  • Steady the shaft of the needle with your non-dominant hand.
  • Talk to the patient. Here are some examples of what you can say prior to the procedure:
    • “I will numb up your back, and that should be the only part that hurts.”
    • “Most of the procedure is just setting up my materials.”
  • During the procedure, the patient cannot see you, which can be anxiety provoking. Describe each step of the procedure in a calm manner. And try to avoid THIS.
  • If necessary, administer an anxiolytic such as a benzodiazepine.

troubleshootingYour patient is very sensitive to pain

  • First, lidocaine!
    • Did you inject enough volume into the deeper structures of the back? As Dr. Whit Fisher mentioned in the comments of the previous post, make sure you gather extra lidocaine (only 5ml in the LP tray). In a sterile fashion, draw up an extra 5-10 ml with the help of an assistant.
    • Note: if trying a new interspace, make sure this area is also anesthetized.
  • Patient still in pain? Consider administration of an analgesic such as an opioid.

Continue reading

Lumbar Puncture Part 1: The Basics

a monthly blog series on procedures


Hunting & Gathering

Find a Workstation on Wheels (WOW) with a functioning Topaz to obtain informed consent.

Place Epic orders for CSF. Print the stickers and sign each with your initials.

Locate an LP tray,  its contents, sterile gloves, eye protection, facemask.

Gather these optional supplies:

  • Extra spinal needles:
    • 20 gauge, 3.5 in Quincke = cutting needle (1 included in tray).
    • 22 gauge, 3.5 in Whitacre = atraumatic needle.
    • 20 gauge, 6 in “Harpoon” = longer needle.
  • Extra 1% Lidocaine (5ml in tray).
  • Extra Povidone-Iodine.
  • Non-sterile marking pen.

Optional: Tech or RN for positioning assistance during procedure.

Timeout!

Perform the LP (see below).

Collect CSF in 4 tubes and send to lab.

Choosing the right needle

The Whitacre needle (aka a type of pencil point needle, or “atraumatic” needle) contains side ports, and theoretically causes less damage to tissue fibers upon entry. They are more difficult to use for skin entry. However, studies have shown that atraumatic needles decrease the incidence of post-LP headache (1 and 2). As an aside, there is no evidence that lying supine for any fixed period time is helpful in the prevention of post-LP headache(3). Continue reading