Who are the real kings of the LP

[neusu]

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Many services do them, who's the best?

I have my own thoughts on this, but wanted to see what the general opinion out there was. FWIW, we do our own. Other services, I believe, make an attempt, and then consult IR if there are issues.

 

[Psai]

Who does the blood patches after you f it up? I rest my case.

 

[badasshairday]

Neurosurgery, anesthesia, and neurology. But for some reason everyone calls radiology for that, including those 3 specialities. I know anesthesia has the votes so far, and that is great keep calling them.... but I still get consults for failed LP by primary team who asked anesthesia to do it, but even anesthesia can't get it.
Then they end up with me on the fluoro table for a 30 second LP on a Saturday morning.

 

[dadaddadaBATMAN]

Anesthesia trained pain medicine doc doing it under fluoro

Or, any attending working under fluoro

 

[badasshairday]

Anesthesia trained pain medicine doc doing it under fluoro

Or, any attending working under fluoro

GooD luck getting a pain management doc do routine inpatients.

 

[SurfingDoctor]

Depends on the age. I wouldn't trust anyone without a pediatric specialty/subspecialty to put a needle in an infants back. Actually, that goes for anything related to childrens care. I've seen too many misadventures by adult physicians for childhood diseases and procedures.

I will say though in pediatrics, the group to get the last poke when everyone else has failed is Interventional Radiology

 

[BigRedBeta]

I mean, if you consider the tools that radiologists get at their disposal "kingmakers" then yeah, it's them. But how do they do without the extra help?

But "typical" patient matters/experience matters. As a PICU attending give me a 3kg baby and I'll get fluid every time (been at least 5 years since I completely missed a tap), and I'm comfortable with doing them on 900 gram NICU babies too...but a 150kg 18 year old? Not in my wheelhouse and I'll be lucky if the children's hospital even has spinal needles long enough to reach the space.

 

[neusu]

Neurosurgery, anesthesia, and neurology. But for some reason everyone calls radiology for that, including those 3 specialities. I know anesthesia has the votes so far, and that is great keep calling them.... but I still get consults for failed LP by primary team who asked anesthesia to do it, but even anesthesia can't get it.
Then they end up with me on the fluoro table for a 30 second LP on a Saturday morning.

I gotta say, more than once on my neuro-IR rotation the rads IR fellows couldn't get an LP, under fluoro, and I waltzed in and got it first stick based on landmarks.

 

[neusu]

Depends on the age. I wouldn't trust anyone without a pediatric specialty/subspecialty to put a needle in an infants back. Actually, that goes for anything related to childrens care. I've seen too many misadventures by adult physicians for childhood diseases and procedures.

I will say though in pediatrics, the group to get the last poke when everyone else has failed is Interventional Radiology

Interesting you say that, yet there are no votes for pediatrics!

 

[IlDestriero]

Anesthesia pain w/ fluoro > IR w/fluoro > anesthesia > EM, neurology, oncology, peds > others


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Il Destriero

 

[SurfingDoctor]

Interesting you say that, yet there are no votes for pediatrics!

I said Pediatrics then Interventional Radiology. Since Interventional Radiology gets to try when everyone fails for kids, I voted for them. But an adult Anesthesiologist for an infant with meningitis, I would hope not.

I suspect the number of people who voted in this who actually treat children is probably low.

The best LP I've ever seen was by a Pediatric Oncologist in a 5 year old with a mediastinal mass and stridor who was thrashing around and using only EMLA. 0 WBCs, 0 RBCs. There was probably a bit of luck, but I was impressed.

 

[WheezyBaby]

Anesthesia ~ peds heme onc for their respective populations, if we're talking without fluoro. I've never seen IR fail a tap under fluoro. Can't comment on nsurg

 

[badasshairday]

I gotta say, more than once on my neuro-IR rotation the rads IR fellows couldn't get an LP, under fluoro, and I waltzed in and got it first stick based on landmarks.

Weakest fellow known to man if that is the case. I've noticed the neurosurgery residents when they rotate through neuroIR seem to try to do a landmark based LP and intermittently check fluoro. Which is fine, but slower, and really isn't taking advantage of fluoro.

 

[neusu]

I said Pediatrics then Interventional Radiology. Since Interventional Radiology gets to try when everyone fails for kids, I voted for them. But an adult Anesthesiologist for an infant with meningitis, I would hope not.

I suspect the number of people who voted in this who actually treat children is probably low.

The best LP I've ever seen was by a Pediatric Oncologist in a 5 year old with a mediastinal mass and stridor who was thrashing around and using only EMLA. 0 WBCs, 0 RBCs. There was probably a bit of luck, but I was impressed.

While we're at it, do you guys let the first drop or so fall on to the field or do you send that as well?

 

[WheezyBaby]

While we're at it, do you guys let the first drop or so fall on to the field or do you send that as well?

First 10 drops onto field, tube 4 for cell count. Champagne errytime

 

[Crayola227]

not sure why EM is on the list. there's really a few cases where it's being done so emergently it doesn't wait for someone else to do it, most ED docs I've talked with don't do them as often as, say, anesthesia or IR

 

[dadaddadaBATMAN]

not sure why EM is on the list. there's really a few cases where it's being done so emergently it doesn't wait for someone else to do it, most ED docs I've talked with don't do them as often as, say, anesthesia or IR

Must be an institutional thing.

Usually one every other shift at our place, and most pediatric ones are done by ED. I am guessing the pediatrics guy above remembers H inf./the days when hospitals were filled with itty bitty meningitis cases. Otherwise that comment doesn't make much sense to me

 

[Zebra Hunter]

not sure why EM is on the list. there's really a few cases where it's being done so emergently it doesn't wait for someone else to do it, most ED docs I've talked with don't do them as often as, say, anesthesia or IR

I'd get berated if I tried to admit a febrile 4wk old without a tap. If I think the pt needs a tap, I tap them. It's pretty poor form to admit a suspected or r/o meningitis without at least attempting a tap.

 

[tiedyeddog]

Interesting you say that, yet there are no votes for pediatrics!

Kids are incredibly easy to get. Try getting one on an 80 year old obese the patient with multi-level degenerative disease with a scoliotic spine. Or even better, a 30 year old 450 pound patient with idiopathic intracranial hypertension. Kids lack this kind of stuff plus it's a shorter space from skin to thecal sac so you have less room for error.

Edit: haha didn't see who I was replying to, my bad, please take no offense to this.


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[tiedyeddog]

Weakest fellow known to man if that is the case. I've noticed the neurosurgery residents when they rotate through neuroIR seem to try to do a landmark based LP and intermittently check fluoro. Which is fine, but slower, and really isn't taking advantage of fluoro.

That's what they are supposed to do. We should be able to do them without fluoro as we don't have it available on the floor. Plus, when I have done it under fluoro I use it intermittently to see what I could have done differently to get it with landmarks only.


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[tiedyeddog]

Anesthesia ~ peds heme onc for their respective populations, if we're talking without fluoro. I've never seen IR fail a tap under fluoro. Can't comment on nsurg

I have seen them fail it under fluoro done by an IR attending with 30 years experience. It happens.


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[tiedyeddog]

Many services do them, who's the best?

I have my own thoughts on this, but wanted to see what the general opinion out there was. FWIW, we do our own. Other services, I believe, make an attempt, and then consult IR if there are issues.

Getting to the original question, IR doesn't count in that mix. They use flouro. That's a different ballgame.

I wild guess this would be institution dependent and different if you're counting kids or not. Neurosurgery is the best at my institution. I know at some places neurosurgery hardly ever does then as a NP will do them as part of a team(or so some residents at other institutions tell me).


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