Feasibility of ultrasound‐assisted lumbar punctures performed by pediatric oncologists at the point of care

Abstract

Background: Ultrasound assistance improves success rates and reduces adverse outcomes of lumbar punctures (LPs) among adult patients in the emergency room and the operating room, but has not been evaluated in pediatric patients with cancer.Our objectives were (1) to determine whether pediatric oncologists could perform ultrasound-assisted LPs following a structured teaching curriculum, and (2) to determine the feasibility of recruiting pediatric cancer patients to a clinical trial of this procedure.Methods: Three pediatric oncologists completed a curriculum composed of didactic teaching followed by hands-on workshops. Each learner was evaluated during 20 attempts at three ultrasound tasks using the cumulative sum method. The three pediatric oncologists then performed ultrasound assessments prior to routinely scheduled LPs. Feasibility was defined as ability to perform at least 30 ultrasound-assisted LPs within 6 months. Secondary outcomes were the proportion of successful, bloody, or traumatic LPs, time required, and perceived helpfulness of ultrasound.Results: All three pediatric oncologists achieved competence in the three tasks of ultrasound scanning within 20 evaluated attempts. We recruited 62 patients within 1 month, and 58 underwent an ultrasound-assisted LP. All LPs were successful. Two LPs (4%) had ≥500 red blood cells (RBCs)/µl, and nine (16%) had ≥10 RBCs/µl. Median time to conduct the scan was 1.9 minutes (range 0.8-4.0 minutes). In 37 (64%) of the LPs, ultrasound assistance was considered helpful or very helpful.Conclusions: Pediatric oncologists readily achieved competence in ultrasoundassisted LPs, and ultrasound was commonly perceived as helpful. It is feasible to proceed to a randomized trial of this procedure in pediatric cancer.

Bioimpedance spinal needle provides high success and low complication rate in lumbar punctures of pediatric patients with acute lymphoblastic leukemia

“…This finding not only underlines the importance of the first attempt in getting a high-quality CSF sample but also compares well to halved incidences of TLPs reported after successful first attempts in adults with leukemia or neurologic problems 16 , 27 , and children in general 17 . The present 10% incidence of TLP associated with the successful first attempts agrees well with the 16% incidence observed in a recent study where the overall success rate at the first attempt was 90% 15 . Sedation most likely accounts for the low incidence of TLP among the pediatric patients with ALL, but acceptable results may also be obtained in intrathecal treatment LPs without sedation 28 .…”

“…The success of LP at the first attempt achieved with the novel bioimpedance needle system was about 80%. Comparing this value to previous studies of pediatric patients with ALL is congruent with the 70% success rate achieved by seven experienced pediatricians with a conventional spinal needle 13 , the 90% success rate achieved by three pediatric oncologists with ultrasound guidance after specific training for its use 15 and the 95% success rate without image guidance achieved by a single, highly experienced pediatric oncologist 14 . Clinically, the most relevant result of the present study is that the success of LP at the first attempt was significantly associated with almost four times lower incidence of TLP compared to LP procedures where two or more attempts were required.…”

“…The most considerable LP-specific complication is post-dural puncture headache (PDPH) 10 . In children with ALL, the incidence of PDPH is yet quite low varying from 5 to 14% 11 – 15 . Excellent success at the first attempt is likely to contribute to the low incidence of PDPH 14 .…”

“…Success at the first attempt cannot be taken for granted, however. In pediatric patients with ALL, the success of LP with single skin penetration is generally good varying from 70 13 to 90% or more 14 , 15 . In adults with leukemia, the success is associated with about halved incidence of TLP 16 , but to our knowledge, this issue is not specifically addressed in children with ALL.…”

Reducing sedated lumbar punctures in pediatric patients with acute lymphoblastic leukemia

“…The increased incidence of traumatic LPs without sedation supports our reasoning to avoid this technique at diagnosis. Given this experience, additional proven strategies to improve LP techniques such as ultrasound guidance are being explored at our institution to enhance technique efficiency 8 …”