1. 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 INVESTIGATORS: Soheil Samvatian PGYIIIFM Maisara Rahman PGYIIIFM

2. 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.

3. 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

4. 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

5. 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

6. 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

7. 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

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

9. 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

10. 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

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

12. Reasons for Lumbar puncture

13. 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

14. Histogram of the causes

15. 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)

16. 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

17. 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

18. 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

19. Cont C reactive protein

20. 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> RBC and 2cases >500 RBC
13 cases Lumbar puncture were completely successful
2 cases was dry tap

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

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

23. Cont, retrospective study
Among 40 cases were performed by
Attending 20 cases
PGYI cases
PGYII cases
PGYIII cases

24. Location of procedure Pediatric floor 15 cases NICU 8 cases
ER cases
PICU cases

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

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

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

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

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

30. 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.

31. Lateral recumbent position

32. 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.

33. Sitting position

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

35. 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

36. 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

37. 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

38. Manometery

39. 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

40. 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

41. 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)

42. 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

43. 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

44. 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

45. 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

46. 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)

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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 )
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 )
Eventually ,observational evidence suggests that using a local anesthetic increases the likelihood of a successful procedure

56. 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

57. 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