1. Lumbar puncture Dr. Mohamed Haseen Basha Dr. Mohamed Haseen Basha Assistant professor ( Pediatrics) Faculty of Medicine Al Maarefa College of Science and Technology

2. CSF Pathway

3. Indications Diagnostic: Suspected Meningitis, Encephalitis, Brain abscess, Subarachnoid haemorrhage, Gillian Barre Syndrome. Additional : Peudotumor cerebri Intrathecal antibiotics Chemotherapeutic agent instillation

4. Indications in < 1yr Sepsis evaluation – neonate Atypical febrile seizures Febrile children with suspected bacteraemia Mental status change with no identifiable cause

5. Contraindications Increased intracranial tension Cardiac, Pulmonary instability Soft tissue infection over lumbar spine area Severe bleeding or clotting disorder

6. Equipment's 20 gauge spinal needle Syringes and needles (22 and 25 gauge) for spinal anesthesia Manometer with stopcock Sterile drapes, gauzes, brushes and bandages for prepping skin Local anesthetic

7. LP needles & stylet separated

8. a – Ligamentum flavum b – interspinous ligament c – supraspinous ligament Anatomy

9. Normal CSF Values Appears to be clear and colorless Opening Pressure ~ 120 mm/H 2 0 Protein level ~ 35 mg% Glucose level ~ 60 mg % (60% of serum glucose) Cells < 5 lymphocytic/monocytic

10. CSF Profile’s

11. Procedure: Apply local anesthetic cream if available. Position child in either the sitting position or lateral recumbent position, with hips, knees, and neck flexed. Keep shoulders and hips aligned (perpendicular to examining table in recumbent position) to avoid rotating the spine. Locate the desired intervertebral space (either L3-4 or L4-5) by drawing an imaginary line between the top of the iliac crests. Prepare the skin in sterile fashion. Drape conservatively to make monitoring the infant possible. Use a 20G to 22G spinal needle with stylet (1.5 inch for children <12 years, 3.5 inches for children ≥12 years). A smaller-gauge needle will decrease the incidence of spinal headache and CSF leak.

12. Overlying skin and interspinous tissue can be anesthetized with 1% lidocaine using a 25G needle. Puncture the skin in the midline just caudal to the palpated spinous process, angling slightly cephalad toward the umbilicus. Advance several millimeters at a time, and withdraw stylet frequently to check for CSF flow. Needle may be advanced without the stylet once it is completely through the skin. In small infants, one may not feel a change in resistance or “pop” as the dura is penetrated. If resistance is met initially (you hit bone), withdraw needle to the skin surface and redirect angle slightly.

13. Send CSF for appropriate studies. first tube for culture and Gram stain, second tube for measurement of glucose and protein levels, last tube for cell count and differential. An additional tube can be collected for viral cultures, polymerase chain reaction (PCR), or CSF metabolic studies if indicated. If subarachnoid hemorrhage or traumatic tap is suspected, send the first and fourth tubes for cell count, and ask the laboratory to examine the CSF for xanthochromia.

14. Accurate measurement of CSF pressure can be made only with the patient lying quietly on his or her side in an unflexed position. It is not a reliable measurement in the sitting position. Once free flow of spinal fluid is obtained, attach the manometer and measure CSF pressure. Opening pressure is recorded as the level at which CSF is steady.

15. Position of patient Incorrect Correct

16. Lumbar puncture site in sitting position. Lumbar puncture site in lateral (recumbent) position.

17. Painting area

18. Starting point of painting

19. Draping

20. Local anaesthesia

21. Needle entry

22. After care Position after LP: head low for 24 hr Sterile dressing Headache: Analgesics

23. Complications Local Pain, Infection, Bleeding, Spinal Fluid Leak, Hematoma, Spinal Headache, Cerebral Herniation