Lumbar Puncture

DOCUMENTATION

EQUIPMENT

  • Lumbar Puncture Kit
  • Iodine
  • Sterile Gloves
  • Sterile Gown
  • Faceshield

PROCEDURE

  • Positioning: patient should be placed either in the lateral decubitus position or sitting and leaning forward. If an opening pressure is needed the patient must be in the lateral decubitus position. The patient should be flat, hips aligned, and the spine should be straight.
  • Locate appropriate landmarks: feel for the posterior superior iliac crests and feel midline at this level. The protrusions at midline are the spinous processes of L3-L4. The needle can be inserted between the spinous processes at L2-L3, L3-L4, or L4-5, L3-4. These can be difficult on obese patients and it can be helpful to locate the sacral promontory. The top of the sacrum is the interspace L5-S1. One space above this is L4-L5. Mark the chosen space so that it can be identified later.
  • Put on gown, mask with face shield, and gloves and open the Lumbar puncture kit.
  • Prep and drape the area surrounding the indentified area.
  • Use the lidocaine 1% with or without epinephrine to anesthetize the skin. Initially a wheel is placed directly under the skin. The area deep to this is then anesthetized all the way to the periosteum. Of note, the bottle in the kit is often not sufficient and additional lidocaine can be ordered.
  • Unscrew and set up the 4 sterile containers so that they can be accessed easily.
  • Assemble manometer by attaching the two pieces together and then attaching it to the 3-way stopcock. The tubing is also attached to the 3-way stopcock.
  • Insert needle bevel-up (bevel to the side if sitting up) through the skin at a slight cephalid angle towards the navel. Advance through the deeper tissues. 1-2 slight pops or gives are usually felt when the ligament and dura are punctured. If you hit bone, withdraw the needle slightly to be able to reposition, and re-advance the needle.
  • When the needle feels like it is in, remove the stylet and watch for CSF return.
  • When CSF returns, attach the 3-way stopcock and measure ICP if in the lateral position (> 20 cm is abnormal).
  • Once the ICP has been recorded begin filling sterile tubes 1-4 in order with 1-2 ml of CSF in each

Tube 1: cell count and differential

Tube 2: glucose, protein

Tube 3: bacterial, viral, and fungal cultures

Tube 4: cell count and differential

  • After tap, remove needle, and place a bandage over the puncture site.
  • Instruct patient to remain lying down for 1-2 hours before getting up to reduce the incidence of post-LP headache

PROCEDURE NOTE

Date:

Indication:

Resident:

Attending:

Patient was evaluated and required lumbar puncture for above reason.Consent was obtained and a time-out was completed verifying correct patient, procedure, site, positioning. The patient was prepped and draped in sterile fashion. The area was anesthetized with 1% lidocaine with(?)with out epinephrine. The needle was inserted at L3-L4(?)L4-L5(?)L2-L3. Opening pressure was(?)was not obtained and found to be less than 20mm Hg. 4 sterile tubes were filled with 1mL of CSF. The needle was then removed and bandage was placed.Patient tolerated the procedure well and there were no complications.