When do you guys LP?

[gman33]

How aggressive are you guys with working up meningitis?

This is something I've been thinking a lot about recently.

Some cases are very obvious, others not so much.

I've had a few cases recently, fever + HA for days with no other clear source.
My thinking is that meningitis (bacterial) is a devastating illness that will lead to a bad outcome if missed.
So I pretty much LP, abx, OBS all of these patients.
I don't want to miss anything bad, but I really don't want to miss something like this in a young person.

I know a lot of these cases will turn out to be viral meningitis, or some non specific viral illness.
If the person is toxic appearing, the decision is easy.
It's more difficult when the person looks decent.

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[Dre8]

You obs all fever plus HA patients even after LP?
I don't even LP every patient who has a fever and HA (if I assume the fever is causing the headache, even without a source), let alone observe them in the hospital. I have no problem calling something a viral syndrome, but now I'm wondering if I'm playing with fire.

I do not mean this to be a rude question, but what is your practice environment? I assume you must be in academics...if not, I'm curious about your numbers in the community.

 

[DrJavaSunflower]

How aggressive are you guys with working up meningitis?

This is something I've been thinking a lot about recently.

Some cases are very obvious, others not so much.

I've had a few cases recently, fever + HA for days with no other clear source.
My thinking is that meningitis (bacterial) is a devastating illness that will lead to a bad outcome if missed.
So I pretty much LP, abx, OBS all of these patients.
I don't want to miss anything bad, but I really don't want to miss something like this in a young person.

I know a lot of these cases will turn out to be viral meningitis, or some non specific viral illness.
If the person is toxic appearing, the decision is easy.
It's more difficult when the person looks decent.

I don't have an answer. But, I think we do way too much defensive medicine.. and our clinical judgment is often required to take into account of "what you would say to the judge for what you did not do and why you did not do".

 

[DarkHorse22]

if someone has had a fever and HA for days and is still alive and not particularly toxic looking, I think you have ruled out bacterial meningitis, no?

 

[gman33]

I practice in a very high volume community shop.
I find it much easier to admit/obs than at an academic place where you are dealing with residents who are trying to avoid work.

I may have not clearly stated my thinking.
I don't LP all HA + fever.

I've done it maybe 4 times in the past year.
2+ bacterial meningitis, 1+ bacteremia. 1 I'm not sure about because I have to check some results that were still pending when I left the dept.

A low risk, well appearing person, probably would just get d/c with no testing.
There has to be something else going on in my mind.
Sometimes there are obvious things.
Sometimes it's more subtle, maybe I can't even fully explain why I'm worried.
I am starting to trust my clinical judgement more, and if something is bothering me, I'll have a pretty lengthy discussion with the patient about my concerns.

If and when possible, I try to practice shared decision making.
I don't strong arm anyone into doing something they don't want.
I am not the guy that orders every test and admits everyone.

I'm probably closer to the opposite end of the spectrum.

Here is my explanation for the OBS.

If the LP come back totally neg, most of these people could probably be sent home.
I work a lot of evening/overnight shifts.
CSF samples generally take a good bit longer at those times.
There is also the issue of blood cultures and their follow up.

Where I work, there is a push to get people out of the dept ASAP.
Usually patients have been in a room for a while by the time I get some labs, +/- CT and have an LP done.
Let's say that's 2 hours in a good case.
Keeping them in the room for another 2-3 hours while waiting some additional results is a long time.
There is also a possibility given that long workup time, they may need to be signed out to another doc.

I would rather just put them in an OBS bed, clear the room, and than they will be in the hospital when all CSF and maybe prelim blood cultures come back.

Now if I was doing this on everyone with a HA and a cold, that would be crazy and I'm sure I'd be shown the door at my job.

I'm talking about a very small number of patients. No more than 2-3 a year would be my guess.
And these are people that usually got a really good look for any other reasonable source.

 

[HooliganSnail]

How aggressive are you guys with working up meningitis?

This is something I've been thinking a lot about recently.

Some cases are very obvious, others not so much.

I've had a few cases recently, fever + HA for days with no other clear source.
My thinking is that meningitis (bacterial) is a devastating illness that will lead to a bad outcome if missed.
So I pretty much LP, abx, OBS all of these patients.
I don't want to miss anything bad, but I really don't want to miss something like this in a young person.

I know a lot of these cases will turn out to be viral meningitis, or some non specific viral illness.
If the person is toxic appearing, the decision is easy.
It's more difficult when the person looks decent.

I feel like I don't LP people often, which probably means that I'm not doing it enough. As a procedure, it is one of my least favorite, I feel like they are usually very low yield, and the patient is awake and it hurts a ton. It is right up there with the awake art line.

What you are talking about is the most difficult medical decisions, the "in-betweeners" Not quite obviously toxic, not quite totally fine.

I suspect your clinical decisions are spot on. Sometimes it's easy to get into a funk and question your decisions, but in reality, I bet your doing just the right amount.

 

[badasshairday]

LP's are getting harder and harder to do at bedside with the ever expanding American waistline. I'd imagine there are times you may want to do an LP but it is just not possible. We are seeing more and more coming from the ER and floor for fluoro guided LP in radiology.

 

[dotcb]

It is a low yield test in the sense that you have to LP a lot of patients to actually diagnose meningitis. Sort of like you have to CT a lot of aortas to find a dissection. (low disease prevalence, high morbidity/mortality)

I do an LP if I want to rule out meningitis and can't with clinical judgement or find another source. I admit a patient +/- give antibiotics if I'm concerned for sepsis with unknown source…

 

[WilcoWorld]

if someone has had a fever and HA for days and is still alive and not particularly toxic looking, I think you have ruled out bacterial meningitis, no?

Yeah, unless they got a dose of Rocephin on day 1.5 of the fever.

 

[gman33]

I've been thinking a lot about how I make decisions.
I've read a few books recently on this topic.

Research would indicate that if a certain decision is going to create a lot of extra work on our part, our brain will try to convince us that there must be another answer. Usually this occurs without any conscience thought.

I think an LP falls under this pathway.

I see plenty of people (myself included), ordering CT scans on this type of patient.
The CT is a very low yield test in this population, and if you believe the radiation data, there is a chance it will be harmful.

But, it is a very easy test to get, and requires virtually no effort on out part.
In many cases, it will decrease effort, as we don't have to explain to the patient why we aren't getting a CT.

If the LP was an easy, painless test (which it's not) and we had to do the CT ourselves (which we don't), I wonder if people would get LPs instead of CTs in these cases.

I'm not saying we should LP instead of CT, just pointing out a bias in the decision making process.

What I have started doing is trying to recognize this bias in my decision making process.
When I realize I am trying not to do something because it takes a lot of effort, I am forcing myself to at least analyze my thought process.

 

[Tiger26]

Just got our billing data for last year and apparently I do these twice as often as my colleagues, so I have a fairly low threshold. With that said, if I think meningitis, even viral, it's easier to do it than miss the diagnosis.

I'm good and the procedure and quick at it, so it's not a huge deal.

I find that a lot of my colleagues do them less frequently because they're apprehensive about their clinical skills and likely success rate.

 

[turkeyjerky]

Just got our billing data for last year and apparently I do these twice as often as my colleagues, so I have a fairly low threshold. With that said, if I think meningitis, even viral, it's easier to do it than miss the diagnosis.

I'm good and the procedure and quick at it, so it's not a huge deal.

I find that a lot of my colleagues do them less frequently because they're apprehensive about their clinical skills and likely success rate.

Honest question, why do you care about viral meningitis?

 

[GeneralVeers]

Honest question, why do you care about viral meningitis?

Agreed. I don't care about viral meningitis either. Only reason to LP is for bacterial meningitis. If people are sick enough to need an LP, I'm going to admit them to the hospital anyway.

 

[RustedFox]

Just got our billing data for last year and apparently I do these twice as often as my colleagues, so I have a fairly low threshold. With that said, if I think meningitis, even viral, it's easier to do it than miss the diagnosis.

I'm good and the procedure and quick at it, so it's not a huge deal.

I find that a lot of my colleagues do them less frequently because they're apprehensive about their clinical skills and likely success rate.

A lot of confidence and success rate is dependent upon your patient population. My average patient with headache and fever is 70-plus, and has a spine that looks like a prehistoric snake. I'm not keen on LP'ing them. I miss LOTS of LPs.

 

[Tiger26]

Honest question, why do you care about viral meningitis?

I don't think I'll ever be as good of a clinician at separating viral vs bacterial as the CSF analysis ...

 

[UnderwaterDoc]

I don't think I'll ever be as good of a clinician at separating viral vs bacterial as the CSF analysis ...

I never LP if I think is viral meningitis. I think history is what diagnoses this, in my mind bacterial meningitis is a rapid, toxic process that will make the patient look sick/altered rather quickly. The several day old headache with fever falls into "viral syndrome" in my eyes which I will not LP. Looking back in the 19 months I've been out I have probably done 5-6 LPs. Only result of any significance was an HIV guy that ended up having cryptococcal meningitis. everybody else was viral/negative. I don't even bother LP'ing for SAH because our neurosurgeons do not trust the LP results and they always request MRI/MRA, hence in people that I am reasonably concerned about SAH I will get a plain CT and then admit for MRI/MRA (this is very rare and I have probably done it 2-3 times).

 

[gman33]

I agree that the LP for SAH is very low yield.
If there is blood, you still need to go looking for an aneurysm.

It is very rare that I do an LP for that person.
I am more likely to get additional imaging if I am really concerned.

I did have a guy that I was sure had some type of bleed.
Came in with HA for a week, not toxic, but had bradycardia and HTN.

Neg head CT. But I was sure he had a bleed.
Did the LP.

Crypto Meningitis with new dx of HIV (after the LP and additional testing).

This was an old guy, where I never suspected meningitis, HIV or other stuff.

Without the LP, he would have likely had a terrible outcome.

I am not saying that one outlier means you have to LP everyone.

Just saying that if things don't add up, I just consider what tests might be helpful.

The LP is a big pain in the ass (or back) for everyone.

 

[goodoldalky]

I don't think I'll ever be as good of a clinician at separating viral vs bacterial as the CSF analysis ...

This assumes that you have some suspicion for bacterial meningitis to begin with. If I have a young, well-appearing, healthy person with four days of myalgias, headaches, and fever, it's not bacterial meningitis. I have ruled it out. To do a lumbar puncture is a waste of time. (Note, this is not the case in someone with cancer, transplant, HIV, very young/very elderly, etc.)

If I am doing a lumbar puncture it means that I am concerned for bacterial meningitis based on some of those factors. Unless it comes back clear I also admit all of these patients based on my clinical suspicion.. not the CSF. What do you do with your patients with 4 days of fever and headache who have "viral meningitis" appearing CSF after you tap them?

With regard to the SAH discussion, in my opinion, it is all about patient selection. If someone has a textbook SAH and my clinical impression is, "holy crap, that person has a subarachnoid," I'll do the tap if the CT is negative. If my impression is, "Well, sounds like nothing, guess I have to get a CT (because of X,Y,Z)", then I am pretty well done if my pretest probability is that low even before CT. I don't typically tap in these cases.

 

[emergentmd]

Early in my career - alot of LPs for worse headache and rule out meningitis.

fast forward to 15+ yrs of experience and many neg Lps

I Rarely do them now. I never do it for worse Headache of my life. I work in a busy shop and probably did 1 LP last year. In short, i have to have a high suspicion to LP someone. Someone with complaint of fever and neck stiffness better have a stiff neck on exam and look bad.

Worse headache of my life? CT/CT angio will do the trick.

 

[GeneralVeers]

Early in my career - alot of LPs for worse headache and rule out meningitis.

fast forward to 15+ yrs of experience and many neg Lps

I Rarely do them now. I never do it for worse Headache of my life. I work in a busy shop and probably did 1 LP last year. In short, i have to have a high suspicion to LP someone. Someone with complaint of fever and neck stiffness better have a stiff neck on exam and look bad.

Worse headache of my life? CT/CT angio will do the trick.

I exactly agree. I've ruled out bacterial meningitis based on patient appearance and length of illness.

For SAH with the NNT being 700 LPs to diagnose 1 SAH, I'll play the odds on that one. Say I have one patient a week that would meet headache criteria for LP and has a negative CT. That means ~50 patients per year. If I LPed every one of them it would be 14 years before I'd miss a SAH. To me that's an almost worthless, time-consuming test with limited benefit.

 

[shoal007]

Two viral meningitis you don't want to miss is Lyme and encephalitis is hsv. So I certainly do l.p. people I think have viral when I suspect these 2 variants.

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[Tenk]

I LP for two reasons:

1) Fever + Headache (or AMS) + Sick = LP.

2) Google + Patient = LP.

 

[emergentmd]

Oh BTW, my rate of LPs goes up more in the daytime and less at night. I think I did 1-2 LPs last year, rest done by radiologist.

Daytime = interventional radiologist
nightime = just me.

 

[shoal007]

... Lyme is not viral. Did you really think we treated a virus with doxy?

Oops you are correct, it's symptoms and LP results mirror viral meningitis presentations


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[WilcoWorld]

I LP for two reasons:

1) Fever + Headache (or AMS) + Sick = LP.

2) Google + Patient = LP.

I will LP in two situations:

1) I think that the patient has a diagnosis that I need to make AND I need an LP to make that diagnosis.

OR

2) I don't really think it's bad, but I can't rule out the diagnoses that I need to rule out (usually due to a pan positive ROS) AND the patient fails to decline an LP.

 

[Arch Guillotti]

the patient is awake and it hurts a ton. It is right up there with the awake art line.

If you use local, neither one of these procedures should be all that painful.

 

[e30ftw]

I "acceptably exclude" meningitis in the majority of patients with CC: "fever, headache" with history, VS, clinical appearance, and physical exam including jolt accentuation.

If they've google'd meningitis or had a grandparent, etc with bacterial meningitis I can usually convince them of a viral syndrome with PE/hx/discussion of clinical course of meningitis, +/- labs and IVF.

This is only for well-appearing patients who present complaining of "Fever, headache" and want to be evaluated for meningitis. Obviously someone who is febrile, toxic, and altered without another source gets LP'd and admitted.

I agree that an LP done well should not be significantly painful. Obesity can make the procedure much more difficult than it should be but if you have the opportunity to tap a young 60kg patient without vertebral disease they usually don't feel much after the lidocaine.

 

[RustedFox]

I "acceptably exclude" meningitis in the majority of patients with CC: "fever, headache" with history, VS, clinical appearance, and physical exam including jolt accentuation.

If they've google'd meningitis or had a grandparent, etc with bacterial meningitis I can usually convince them of a viral syndrome with PE/hx/discussion of clinical course of meningitis, +/- labs and IVF.

This is only for well-appearing patients who present complaining of "Fever, headache" and want to be evaluated for meningitis. Obviously someone who is febrile, toxic, and altered without another source gets LP'd and admitted.

I agree that an LP done well should not be significantly painful. Obesity can make the procedure much more difficult than it should be but if you have the opportunity to tap a young 60kg patient without vertebral disease they usually don't feel much after the lidocaine.

A whaa... ?

 

[Old Grunt]

I am really sympathetic to how uncomfortable an LP can be for patients after my wife had an LP for rule out meningitis (it was negative) and ended up having a spinal headache for several days and truly had "the worst HA of my life". So I really make sure patient's understand the risks and benefits.

That being said, I've probably done at least 6 LPs in the last month. I think a lot of it is - at least in the case of meningitis - I am not fully comfortable with ruling someone out clinically if the case is vague.