Neonatal/Infant LP's... tips & tricks?

[Daiphon]

hey all...

so, i've had a few LP's on kids < 3mo old (good ol' septic workup), and i wondered if there were any tips on how to minimize traumatic taps (other than just practice, practice, practice). since they're so young, there's virtually no give to the spinal ligaments... and it makes it hard to know when you're far enough in.

mostly, i'm not a big fan of mathematics, and the RBC/WBC ratio for traumatic taps - while useful - is beginning to haunt me in my post-shift haze...

any thoughts appreciated. d=)

-t

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[bartleby]

First of all, you're only going to be as good at the LP as your assistant is good at keeping the little bucking bronco still. No moving targets. This is not a job for a family member, nor is it a job for a PCA/tech/nurse with a light tough. They firmly, but gently, need to keep the infant with his/her trunk flexed and on the stretcher.

You know what it says on your car's side view mirror? Ditto for LPs in the young'uns. The distance between the epidermis and the dura is quite short. There are two things you can do to help address this, the first of which involves removing the stylet to check for CSF flow every time you budge the needle once you're through the epidermis. Tedious, yes, but once you've gone far and hit the venous plexus on the far side of spinal canal, you've guaranteed yourself thousands of reds in your sample.

An alternative for once you're really comfortable with you techniques/landmarks is (with the stylet in place) to puncture the epidermis, advance, and then remove the stylet once you near the dural space. This allows you to see the flash of CSF when you've first reached the space, not when you're already too far through it. Removing the stylet near to but dorsal to the dura is acceptable as you've already avoided the chance of coring a sample of epidermis and dragging it into the spinal canal by punctuing the epidermis/dermis with the stylet in place.

And a particuarly appropos saying of one of my favorite attendings is, "I'd rather be lucky than good any day!".

so, i've had a few LP's on kids < 3mo old (good ol' septic workup), and i wondered if there were any tips on how to minimize traumatic taps (other than just practice, practice, practice).

 

[KidDr]

First of all, you're only going to be as good at the LP as your assistant is good at keeping the little bucking bronco still. No moving targets. This is not a job for a family member, nor is it a job for a PCA/tech/nurse with a light tough. They firmly, but gently, need to keep the infant with his/her trunk flexed and on the stretcher.

You know what it says on your car's side view mirror? Ditto for LPs in the young'uns. The distance between the epidermis and the dura is quite short. There are two things you can do to help address this, the first of which involves removing the stylet to check for CSF flow every time you budge the needle once you're through the epidermis. Tedious, yes, but once you've gone far and hit the venous plexus on the far side of spinal canal, you've guaranteed yourself thousands of reds in your sample.

An alternative for once you're really comfortable with you techniques/landmarks is (with the stylet in place) to puncture the epidermis, advance, and then remove the stylet once you near the dural space. This allows you to see the flash of CSF when you've first reached the space, not when you're already too far through it. Removing the stylet near to but dorsal to the dura is acceptable as you've already avoided the chance of coring a sample of epidermis and dragging it into the spinal canal by punctuing the epidermis/dermis with the stylet in place.

And a particuarly appropos saying of one of my favorite attendings is, "I'd rather be lucky than good any day!".

It's all about the set-up--always adjust the bed to your height, find your landmarks and mark the back before you betadine it, have an extra spinal needle available (cause if you always have an extra, you'll never need it!), have an extra set of sterile gloves available, and most important, you need a great holder to keep the child still!

I used to advance the needle until I was in the spinal canal before removing the stylet and that tended to work well, but now I almost always remove the stylet after puncturing the skin, then advance until I get CSF, and I like this technique even better. Almost always get 0-2 RBC/WBC with it.

I am right-handed, so when I'm doing an LP the baby is laying on its left side with its head on my left side. I prep/drape the back, then with my left hand I place my index/middle fingers on the baby's iliac crest, and place my thumb on the spinous process just above the space I am going to enter. This allows me to stabilize the needle and keep my landmarks even when the baby inevitably moves.

Oh, and if the parents stay in the room, I ask them to sit down, just in case. I don't want any parents fainting during the procedure.

 

[pinbor1]

Hey Daiphon

Here's the tips that I have, their pretty much the same as everyone else:

1. Positioning, positioning, positioning. Make sure to prep the patient well and assess your landmarks. You need a good holder, someone that will keep them from squirming. I also tend to put a pulse ox or monitor on these kids because I'm always paranoid about them not breathing from being held to tight.

2. For kids less than 28 days, I will occasionally use a sterile butterfly needle, with the tubing cut off. The needle tends to be just long enough to reach epidural space, and it is easier to manipulate. For those older than 1 mos, I tend to insert the needle with stylet through the skin, usually I will pull out the stylet and advance the needle until I feel a break in resistence, see flow, or if I hit bone.

3. And again practice, practice, practice...

If you want a demonstration, ask and I'll show you at the next conference.

pinbor1

 

[Febrifuge]

Speaking as that PCA/tech, I was humbled one time when one of the staff docs had an extra-tough time with a little one. I was way too afraid of hurting the kid, and it was a tough stick in any case. So I asked for and got an impromptu clinic on the way to do it right. Turns out it's very similar to a wrestling move called "the cradle," appropriately enough.

It's basically a pretzel motion with the holder's arms; the kiddo's neck and shoulders are under the crook of one arm, and the other arm pins the waist and tucks up the kiddo's legs. The holder's two hands come together and lock underneath and in front of the kiddo, who is now going NOWHERE. The holder needs only avoid dripping forehead sweat in your sterile field, and you're good to go.

 

[Homunculus]

ditto everyone else said. it's postitioning and practice. i still find that most of the time if i miss i'm either to shallow or trying to tap the poor kids sacrum. just make sure you are high enough, aim for the umbilicus, and go for it 🙂 it's more of a pressure or density change for me-- definitely no pop. i swear some of the old farts i did before i started my peds residency had audible LP's, lol.

as a sidenote, in my brief experience with cell counts and traumatic taps-- they're useless. the peds ID folks here tell us no matter what voodoo mathematical equation you use, its predictive value is nil. you really shouldn't guide your clinical management by it.

--your friendly neighborhood tappin' caveman

 

[Daiphon]

Thanks guys (and gals, mayhap)... aside from lots of practice, i think these'll help me cut a little bit off the learning curve and maybe decrease my traumatic taps...

i 'preciate it! d=)

-t