Hmmm... how about your lumbar punctures?

[DrQuinn]

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I started the thread on conscious sedation, and thought I'd see the thoughts on lumbar punctures.

I treat patients how I'd want to be treated. I use the little bottle of 1% lidocaine, plus another 5 cc of lidocaine, and I usually give 1 or 2 of Ativan. I'd want to be loopy during my LP. I also have them on their side.

The Neurology residents here only use the little bottle of Lidocaine and the patients are often jumping around and crying. Ugh!

I only use the Ativan if the person needs it, though. Real sick people or people with AMS who don't respond much obviously dont' get it.

Any variations?

Q

 

[tigress]

So I'm not a doc yet but I had an LP with basically just a little bit of lidocaine, and it wasn't a big deal. I mean, unless I was just extremely lucky, seems to me like more isn't really needed as long as it's done properly. Granted I had a 104 degree fever at the time, but still...didn't hurt or anything

 

[lawmd]

I fill them up with lidocaine-5-10cc in all directions. at first I was doing them on their side, but had 2-3 in a row with no luck. been doing them upright and have had more success. I will try and alternate every few just to make sure I can do both. So far my biggest success was a 400pounder with no landmarks at all. buried the needle to the hub and then some on the first insertion-bingo, no reds at all!! My attending was amazed.

they really are just a case by case basis-some you think will be a cinch and it ends up in the attendings hands for the 5th attempt, then ones like this...

The ativan is a good idea, and buys you a few more minutes as you set things up or go see another patient-thanks for the tip.

 

[Sessamoid]

I usually use some anxiolysis, and in some cases full-blown conscious sedation. Makes my life so much easier, and far less likely to get a traumatic tap that way. Either sitting or decubitus, proper positioning is everything!

 

[southerndoc]

Don't rush the LP. The reason the 3 cc's of lidocaine in the kit doesn't work is because people don't give it enough time to work. I used to make this same mistake, and once I stopped jabbing them with the needle immediately after using the lidocaine, then they stopped feeling pain. I know, it's hard to stare at the walls for 5-10 minutes with your mask, gown, and gloves on knowing you can't touch anything without compromising your sterile field.

Seriously, give it a shot (no pun intended). Use the small amount of lidocaine in the kit, but wait for it to take effect. Patients can literally have pain free LP's if you do it right.

 

[pushinepi2]

Of course, I am only a fourth year medical student so please take my opinions with a hearty grain of salt and a dash of pepper. That disclaimer made, here goes.....

Its rather progressive to hear residents talk about conscious sedation in relation to some common procedures. I think, at least at my own particular ER, there's lots of internal resistance. Nurses are required to do some more monitoring, fill out more paperwork, etc. But.. it seems intuitive that a relaxed patient would be a bit more amenable to failed attempts. My question about anxiolysis/sedation for LPs would be, "why not?" If there's no contraindication to administering ativan/versed/fentanyl, then why not make the patient comfortable? A patient that's not squirming or screaming makes for a less stressful procedure. My most, "memorable" tap was on an HIV positive 17 y/o in the hospital's PICU. She'd already endured chest tube placement for a pneumothorax, multiple other invasive procedures, and was generally uncomfortable. The intensivist suggested the use of propofol. Since the PICU had the necessary equipment and nurses, the procedure went off without a hitch. The tap was, "champaigne" quality, and CSF was obtained on the first try. Now, if only I could convince attendings to sanction the use of ativan for the incision and drainage of a bartholin's abscess....
Interesting thread.

Pushinepi2

 

[roja]

Quinn-

I'm with you... I like more lido... I also use u/s guided if I cant see/palpate the spinous processes... It's easy-peasy.

 

[docB]

I always use extra lido, no downside to it. Ativan if I think it will help. Sitting if they can do it (I have better success with sitting). As soon as I think I might do a tap I start bolusing them. It helps the CSF to flow quicker and it lessens the post LP HA.

Here's a good tip. I carry a sharpie marker. Once I find my spot I mark it with the marker. The spot doesn't wash off with the Betadine. Ballpoint, the mark with a thumbnail or a needle cap are almost always gone by the time you're done prepping. I find a sharpie to be really valuable in the ED for lots of things, LPs, marking cellulitis, marking measure sites for snake bite, making quick and dirty fax cover sheets, all kinds of stuff.

 

[spyderdoc]

I usually use extra lido, esp on a fattie with no landmarks...
I had to use a 6" spinal needle the other day because my 3 1/2 " needle was sunk to the hub with no csf coming out! Definetly used extra lido for that one!

 

[ERMudPhud]

I never use extra lido-I think landmarks are very important. I do make sure to make a small skin wheal right where I will go in and then use the rest of the lido on a 2 inch needle to inject along the path the spinal needle will go. That also tells me I am in the right place. I then spend a good long time messing around with stuff in the LP kit while I wait for the lido to work. I also make a point of telling the patient everything I am doing since they can't see anything. Even if I am just touching their back to check landmarks I warn them ahead of time.

I 've generally haven't had a problem with people holding still or having pain. Most say it hurt less than their IV.

Who measures opening pressure? I used to only do it when I felt it was really warranted then I missed a bad psuedotumor in a patient that I thought really only had meningitis on the differential. Right after that I started checking it on everybody and very quickly found another psuedotumor and a dural sinus thrombosis.

I've tried the U/S look for the spinous processes but had no luck-of course it was on a >500lb guy who couldn't fit on the CT or flouro tables

 

[aliraja]

this is, by far, one of the most usefull threads we've had in a while - thanks for setting it up, Q.

Personally, I'm a big fan of sitting them up, using a lot of lidocaine, and going slowly. I'm sure that as I get older and wiser I'll use less lido but right now I still need to numb them up like crazy since I'm not always dead-on the first time.

I've given ativan once when I thought they really needed it but, thanks to you guys, will be using it a little more often. That, the sharpie, and bolusing them up - thanks for the advice!

 

[Sheerstress]

How do you usually give the Ativan?

 

[beyond all hope]

I prefer Dilaudid before LPs myself. Opiates are a mild anxiolytic and they're good for the pain from the patient's headache as well as the pain you're about to cause them (because everyone with a headache, AMS and fever is 300 pounds, all on the lower lumbar spine...🙂

The LP it is my achilles heel procedure. I'm pretty decent at just about everything else, never missed an intubation, can close ugly lacs and put peripherals or centrals where no veins exist, but the LP always give me a headache.

I've been lying people down but I'm going to start sitting them up from now on. Less planes to deal with.

 

[Crypt Abscess]

What about patients that have had prior low back surgery? I have had to send a few to rad for fluoro LP- they can tap anyone. I only use one vial of lidocaine, but I almost always give 2 of ativan and 1 of morphine. All of my LPs (~20) are generally well tolerated. The IV bolus is a good idea- nothing like taping someone and only getting a few ccs and not enough for cx etc.

Maybe we can start a new thread about art lines...I am like 1 for 10. Any tips? Crypt

 

[neglect]

Great posts.

I agree with ER mud phud - the lidocaine in the container is generally sufficient. You're not going to numb the periosteum, so it's not worth trying - instead, it's more important to use good position and good landmarks. Take the time to position and find your spot.

There is more than one way to skin cats, also more than one way to do LPs.
Several tips not mentioned that I've found helpful:
- drap patient over their hip. That way, you can feel their hip and further ID landmarks after you've used the lidocaine. I also sometimes find it helpful to follow the spine all the way down.
- NEVER insert the stylet into the trocar when your fingers are near the trocar. Why are you holding that trocar? It's not going anywhere! Hands off - then put stylet in. There is serious potential for stylet going into hand.
- Reassurance and a calm disposition go a long way with an anxious patient. Keeping the family around on the other side of the bed can actually help - so I use ativan only if I'm getting serious vibes that there's going to be a problem - if they don't tolerate the lidocaine well - they get ativan 1 mg.
- The bigger the patient, the more position matters, and the harder it for them to assume good lat decub position - so sit em up. Especially those really thick guys - man are they hard - and they usually need ativan (is it also your experience that the guys need ativan more than the women?).
- Never mess with the needle if you're getting some flow. Slow flow is better than no flow - and then digging around for another 5 minutes.
- The L34 interspace is usually best, but if you're not getting it, sometimes 45 is easier - so try it.
- Last gasp: lateral approach! Any anesthesiologists out there?

Isn't there some data out there that fluids don't help the post LP HA?

Great thread.

 

[anonymousEM]

I always start laying down to try to get pressures since we have a huge HIV+ pop'n (on a med service with 10 pts, 3 were crypto meningitis when I was an intern) but if i'm not really worried about pseudotumor I have a low threshold for sitting them up.

 

[The White Coat Investor]

Good thread.

I'm really surprised so many do conscious sedation. I use Brutane most of the time on the kids and a calm, authoritative disposition on the adults. I've done maybe 30 LPs and haven't had any that I thought needed sedation. I use more lidocaine if the patients are complaining about pain. Otherwise, the 2 ccs in the kit seem to work. My patients routinely complain less about my LPs than my nurses' IVs. Of course if I change from L3-4 to L4-5 I use more lidocaine!

I've found much higher rates of success with doing the LPs in sitting position, then IF DESIRED, lay them down to get opening pressure. I also think draping the hips is key.

I've done patients with prior low back surgery with amazingly few problems. The big problems I've had are the fat elderly. Not only difficult to see landmarks, but tons of osteophytes to boot. It's scary using that 6 inch needle. I just keep imagining hitting bowel with it.