Lumbar puncture in Pediatrics

Lumbar puncture (LP) or spinal tap is the technique of using a spinal needle to withdraw cerebrospinal fluid (CSF) from the spinal cord.

Indications

• Diagnostic: For diagnosis of malignancy and infection as well as measurement of
  CSF pressure
• Therapeutic: For intrathecal administration of chemotherapeutic agents (methotrexate, hydrocortisone, and cytarabine)
• Research: Measurement of drug levels

Personnel Required for Lumbar Punctures

• Pediatrician to perform the procedure
• Registered nurse (RN) to assist the procedure
• Doctor/nurse to observe the patient if sedated

Preparation

Psychological Preparation

• A full explanation of the reasons for LP, what the procedure entails, and the potential risks and complications must be given.
• An age-appropriate explanation should also be given to the child.
• Ensure that the child and family understand what is involved and that any concerns or questions have been adequately addressed. This can be supported by written information sheet. Written/oral consent obtained (institutional policy).
• Option for analgesia and sedation should be discussed with the child and family appropriate to the child condition.
• Parents may wish to stay with the child during the procedure and may help to reassure the child by talking or holding a hand or head stroking. This is appropriate where the child is conscious and before and after any general anesthesia.
• Allowing a child to prepare for the procedure through the use of play is a useful part of the preparation process, for example, with dolls, soft toys/action figures, art, and stories. This is beneficial where time and child condition allows.
• For children with acute lymphoblastic leukemia, initial LP may ideally be performed under short-acting general anesthesia to ensure that the child is still. This may reduce the possibility of a traumatic LP, which could lead to transfer of peripheral blast cells into the CSF.

Physical Preparation

• Review history of prior procedure with the parents.
• If there is any question of raised ICP, a careful fundoscopic and neurological examination is required to rule out papilledema or focal neurological deficit.
  If there is any doubt that raised ICP exists, a CT scan and neurosurgery consultation should be obtained.
• Proper positioning of the child is most crucial to ensure the success.
• The child may be placed in a seated position with neck and spine maximally flexed, with arms resting on a bed side table (older child) or leaning over a pillow and held against a seated assistant (younger child).
• Lateral position with neck bent in full flexion and knees bent in full flexion up to chest, approximating a fetal position as much as possible.
• Drawing an imaginary line between the two posterior iliac crests will allow identification of the L4-L5 or L3-LA interspaces.

Procedure

•  While using sterile technique don sterile gloves.
• Clean, prepare and drape the area.
• Infiltrate skin and deeper tissues with 1%lidocaine. When experienced at performing LPs,may be unnecessary to use lidocaine if EMLA cream has been applied to the skin.
• Review tray setup, ensure that lids of collecting containers are unscrewed and containers are readily available.
• Review patient position and restraint.
• Identify L4-5 or L3-4 interspaces and insert the spinal needle with stylet in place, along the midline with bevel facing upward.
• Proper alignment of the needle is aided by placing the thumb of the non-inserting hand on the spinous process above the interspace being used.
• Direct the needle slightly cephalad along the imaginary line toward the umbilicus and advance it slowly. Resistance may be felt as the needle penetrates the ligamentum flavum and further smaller “pop” may be felt as the needle penetrates dura. These changes are not always felt so the stylet should be frequently withdrawn to look for the presence of CSF. If none is visible, rotate the needle 90° to attempt to free the bevel of any occluding tissue. If no CSF is forthcoming, replace the stylet, advance the needle slightly, and recheck.
• If an opening ICP is required, once CSF is seen in hub, attach the three-way stopcock and manometer to the needle hub. Note the height of the fluid column.
• Collect approximately 0.5-1 cc of CSF sequentially in each of the sterile tubes to be sent for appropriate chemical, cytological, and microbiological tests. The last tube should be sent for the cell mount and differential count as it is least likely to be contaminated with red blood cells (RBCs).
• Replace the stylet prior to removal of the needle as this may reduce incidence of post LP headache.
• Remove LP needle and apply pressure over the puncture site.

Post procedure Care

• A small adhesive bandage should be placed over the puncture site.
• The patient should be kept in recumbent in semi prone position approximately for 6hours post procedure.
• Label the specimens before sending to the laboratory.
• Check for any leakage of CSE.
• Monitor vital parameters.
• Encourage to drink extra fluids for the next 24 hours.
• If headache occurs advice for bed rest.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
4. Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840.
5. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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