Research Study Case-Series Analysis of Risk Factors for Unsuccessful Lumbar Punctures In Patients Less Than 90 days Old in Riverside County Medical Center (RCRMC) in 2007 INVESTIGATORS: Soheil Samvatian PGYIIIFM Maisara Rahman PGYIIIFM

BACKROUND Lumbar puncture is a procedure that is very commonly performed in children. Unsuccessful Lumbar Punctures can cause substantial diagnostic uncertainty and may lead to unnecessary antibiotic use and hospitalization.

OBJECTIVE: To Identify Risk Factors For bloody/Unsuccessful Lumbar Punctures To identify if procedural factors like the use local anesthetic helps in preventing bloody/Unsuccessful Lumbar puncture Analytic reason for Lumbar puncture practically obtained in the Hospital

Hypothesis: Based on the retrospective analysis of 40 charts of performed LP at RCRMC We will identify modifiable procedural factors that are associated with bloody/unsuccessful Lumbar punctures that can be improved

Methods: Retrospective studies of case records, performed lumbar punctures in RCRMC in patients younger than 3 months old Charts reviewed from Jan-Dec 2007 Patients less than 3 months old qualified 40 charts were reviewed 40 Charts: 8 Patients in NICU 32 Patients in pediatric floor

Methods Cont.. Data collection ( Chart Review Grid) Gender Age Reason for spinal tap Birth History Medication CRP,CSF culture,Blood culture,DAT,CSF analysis, Other studies,final diagnosis Hospitalization duration

Methods Cont.. BloodyTap defined as, RBC > 500 Unsuccessful Taps: Lumbar Puncture performed which CSF was sent for limited evaluation, Dry Tap :no CSF was drawn

Data Analysis: Gender (43%)17 cases->female (57%)23 case ->male

Gestational Age AGA,30 newborns SGA ,4 newborns LGA,2 newborns 2 cases unknown 6 cases preterm reported (GA<37 weeks) No post-term reported

Birth History NSVD (Normal Spontaneous Vaginal Delivery),31 cases . GBS positive,2cases,treated at least two times . GBS unknown,14 cases, . GBS negative,15 cases Vacuum extractor ,one case with GBS positive ,treated two times in delivery Cesarean Section ,8 cases Another co-morbidity ,GDM diet controlled(A1)3 cases, Galactosemia one case, maternal substance abuse two cases, maternal syphilis2cases,hypothyroidism/depression one case

Frequency polygons of LP distributed in age (No. of LP/Days)

Reasons for Lumbar puncture

Reason for LP Fever,25 cases Fever with GI symptoms,7 cases ALTE/gasping/apnea,6 cases Rule out congenital syphilis,2 cases Rule out Seizures ,5 cases Respiratory symptoms,3 cases Poor feeding /GI symptoms,3 cases

Histogram of the causes

Hospitalization Admission between 2 days to 142 days! 47% patients discharged after 3 days 2cases hospitalized more than 2 weeks because of other co-morbidities One case LP failed antiviral with antibiotic given for complete course(14 days)

Images and studies: Chest X-Ray 24 cases Head MRI 7 cases Head CT without contrast 6 cases(4 cases before LP taken) Head U/S 1 case EEG 8 cases Kidney U/S 5 cases VCUG 3cases inpatient 2 cases outpatient Echo-cardiogram 2 cases UGI fluoroscopy 1 case

C reactive protein (CRP) In 20 cases measured, which in 8 patients CRP level were more than one One patient rule out congenital syphilis , One case seizure, One case Urinary Tract Infection (UTI) One case pneumonia 4 cases fever with unknown source

C Reactive Protein cont. 12 cases CRP <1 One case Enterovirus Meningitis, One case with Bactremia , One case with rule out seizure, Nine cases with unknown/nonspecific fever

Cont C reactive protein

Cerebrospinal fluid results 3 cases cerebrospinal fluid culture were positive Direct Antigen Test (latex test) for 21 patients ordered which were negative Lumbar puncture for 15 cases attempted limited CSF 10 cases bloody ,which 7case> 10.000 RBC and 2cases >500 RBC 13 cases Lumbar puncture were completely successful 2 cases was dry tap

retrospective study of children<90 days undergoing LP in RCRMC in 2007

Prospective cohort of children undergoing LP in Nigrovic & Neurman study(2003-2005)

Cont, retrospective study Among 40 cases were performed by Attending 20 cases PGYI 3 cases PGYII 5 cases PGYIII 12 cases

Location of procedure Pediatric floor 15 cases NICU 8 cases ER 15 cases PICU 2 cases

Types of anesthesia Local injection lidocaine 1% 6 cases EMLA 7 cases Versed conscious sedation one case No anesthesia 26cases

Successful ratio based on anesthesia 26% no anesthesia 57% EMLA 50% local injection lidocaine

Successful ratio based on physician’s factor 45% Attending 50% PGYIII 0% PGYII 0% PGYI

Frequency Polygon of Unsuccessful LP in age distribution ( Number of LP/Days )

Basics in Lumbar Puncture Position Prep/drape Infiltrative anesthetics or topical anesthetics Technique

Lateral recumbent  The lateral recumbent position is used most frequently. The child is positioned near the edge of the examining table. The child should have the neck flexed and knees drawn upward by the assistant the assistant places one arm around the posterior aspect of the child's neck and the other arm under the child's knees The child's hips and shoulders should be kept perpendicular to the examining table in order to maintain spinal alignment without rotation.

Lateral recumbent position

Sitting position The sitting position may be preferred in children who have the potential for developing respiratory compromise because of hyper flexion of the neck in the lateral recumbent position In addition, this position may improve flow of CSF in very small infants (less than two weeks of age). The assistant grasps one of the infant's arms and one of the legs in each hand while supporting the head to prevent excessive flexion at the neck.

Sitting position

Position in this Research Only one case sitting position performed (by PGYIII ) Fetal position (Lateral recumbent position) were reported for the rest of cases

Technique After Sterile preparation, The spinal needle is checked to ensure that the stylet is firmly in place The spinal needle is positioned in the midline with the bevel parallel (facing up) to the direction of the fibers of the ligamentum flavum This positioning of the needle is thought to decrease CSF leak after the procedure is completed because the needle separates, rather than cuts, the fibers of the dura

Cont. Technique The needle is advanced slowly through the spinous ligaments aiming slightly cephalad toward the umbilicus A "pop" often is perceived as the needle penetrates the dura and enters the subarachnoid space. At this point, the stylet can be removed. Since penetration of the dura is not always obvious and the depth to which the needle must be inserted varies depending on the size of the patient and body habitus, the stylet can be cautiously removed from time to time as the needle is advanced to look for CSF

Use of manometer Opening pressure measurement may be deferred in a struggling or uncooperative patient, or if the LP is performed with the patient in the sitting position, because the measurement may be unreliable Normal opening pressures range from 50 to 200 mm H2O in a relaxed patient in the lateral recumbent position with the neck and legs extended. The range can increase to 100 to 280 mm H2O in patients in the lateral recumbent position with the neck and legs flexed

Manometery

Fluid collection  The CSF should be collected in three to four sterile tubes. Approximately 1 mL The first tube should be sent for Gram stain and bacterial culture and antigen detection, the second for CSF glucose and protein, and the third for CSF cell count and differential Additional tubes may be saved for future studies or used for viral culture, fungal culture, cell pathology, or special chemistries If subarachnoid hemorrhage (SAH) is suspected, four tubes should be collected

Rapid Diagnostic Test Antigen detection by latex particle agglutination was once a routine part of bacterial meningitis This test can be still useful because Gram stained smear or culture may be negative in pretreated patients This test has high sensitivity but has low specificity

CT should be performed before LP Altered mental status  Focal neurological signs  Papilledema Seizure Risk for brain abscess (immunocompromise or congenital heart disease with a right-to-left shunt)

Specific contraindications Increased intracranial pressure (ICP) Bleeding diathesis — Evidence regarding the safety of performing LP in patients with thrombocytopenia or coagulation factor deficiency is limited, Nevertheless, because of the risk of subdural or epidural hematoma formation, it generally is not advised performing LP in patients with coagulation defects who are actively bleeding, have severe thrombocytopenia (eg, platelet counts <50,000/microL), or an INR >1.4 Cardiopulmonary instability Soft tissue infection at the puncture site

What if! Patients with spinal abnormalities (such as spina bifida or severe scoliosis) should be identified. An alternative approach for obtaining CSF (such as performing the procedure under fluoroscopy) may be required for such patients In Poor flow , Pulling the needle back to the subcutaneous tissue and redirecting Removing the spinal needle and attempting the procedure at a different site; a new needle should be used for each additional attempt, if the needle has been removed completely

Bloody puncture  A traumatic puncture occurs when the spinal needle strikes the venous plexus that encircles the spinal cord The CSF typically clears as it is collected if the spinal needle is in the subarachnoid space The spinal needle should be removed if the bloody fluid clots in the hub or does not clear   Predicted CSF WBC count/microL = CSF RBC count x peripheral blood WBC count /peripheral blood RBC count

Bloody puncture Cont, The presence of CSF bleeding results in approximately 1 mg of protein/dL per 1000 RBCs/microL The CSF-to-serum glucose ratio is approximately 0.6 in normal individuals; In traumatized one ,glucose falsely going up

Characteristic of Cerebrospinal fluid Successful lumbar puncture estimated Neonate WBC 6(3-10), RBC1(0-3), Protein 144(54-234), Glucose44(38-56), Infant WBC8(5-12) RBC 0, Protein94(68-121), Glucose48(42-55)

Cerebrospinal fluid results cont, 7 cases local anesthesia recorded (EMLA cream applied) Eutectic Mixture of Local Anesthetic Among 7 patients with local anesthesia applied,4 cases were successful and 2 cases CSF RBC >500 and one case limited. Oral sucrose (sweet ease) given to patients reported( 2 cases ) which both with EMLA was successful LP

Anesthetics Local anesthesia should be provided whenever possible when performing lumbar puncture (LP) in infants Available options include infiltration with lidocaine and/or topical preparations (such as EMLA or LMX-4) Oral sucrose offered to infants on a pacifier is safe and effective when used to reduce procedural pain for single events

What is local Anesthesia EMLA cream, One of the first and most studied topical creams is a eutectic mixture of local anesthetics, a prilocaine 2.5% and lidocaine 2.5% cream. When applied for a minimum of 45 to 60 minutes, extensive evidence supports reduction of pain from IV catheter insertion. In contrast to the other tropical's, EMLA can be left on up to 4 hours, and its duration of action continues an hour after removal. In addition, depth of anesthesia increases up to 6 mm during prolonged application

Side Effect Methemoglobinemia is rare side effect more likely in preterm infants lacking the enzyme to reduce it. Current recommendations limit EMLA to neonates at least 37 weeks gestational age Allergic reaction urticaria , angioedema , bronchospasm ,shock rarely reported

EMLA Application Dosage and Time 0 up to 3 months or < 5 kg 1 g 10 cm2 1 hour 3 up to 12 months and > 5 kg 2 g 20 cm2 4 hours 1 to 6 years and > 10 kg 10 g 100 cm2 4 hours 7 to 12 years and > 20 kg 20 g 200 cm2 4 hours

What about another studies: Among 297 infants ≤ 3 months of age receiving lumbar punctures in an emergency department, LPs performed with a local anesthetic were twice as likely to be successful as those performed without local anesthesia (OR: 2.2, 95% CI 1.04-4.6) In a prospective series describing 1459 children receiving lumbar punctures in an emergency department, procedures performed without local anesthetic were more likely to be traumatic or unsuccessful than those performed with local anesthesia (OR: 1.6, 95% CI 1.1-2.2) Eventually ,observational evidence suggests that using a local anesthetic increases the likelihood of a successful procedure

Bottom-line Chart audits can be useful tools in improvement and safety efforts Of the factors associated with bloody or unsuccessful lumbar punctures in children, lack of local anesthetic use seems to be modifiable

references Up To Date, Lumbar puncture: Indications, contraindications, technique, and complications in children, Last literature review version 16.2: May 2008 Division of Emergency Medicine ,Children’s Hospital and Harvard Medical school, Risk Factor Traumatic or Unsuccessful Lumbar Punctures in Children ,Volume 49,No.6,June 2007 American Academy of Pediatrics(AAP)Department of Pediatrics, Epidemiology and biometry Core, Local Anesthetic and Stylet Atyles:Factors associated with resident Lumbar Puncture Success, Pediatrics Volume 117,Number 3 ,March 2006 eMedicine-Methemoglubolinemia Article Last Updated: Apr 5, 2007