Optimal Position for a Spinal Tap in Preterm Infants

Abstract

Inasmuch as spinal taps in preterm infants are frequently accompanied by clinical deterioration, the optimal position for this procedure was investigated. Three positions were each randomly assigned for five minutes to 17 healthy preterm infants without a spinal tap actually being performed: (1) lateral recumbent with full flexion (flexed position), (2) lateral recumbent with partial neck extension (extended position), and (3) sitting with head support and spine flexion (upright position). Transcutaneous Po2 and Pco2 were monitored in all infants, minute ventilation (V1) in seven, and heart rate and blood pressure in ten infants. Mean transcutaneous Po2 decreased in each of the three positions. This decrease was significantly greater in the flexed (28 ± 8 mm Hg) as compared with the extended (18 ± 8 mm Hg, P < .001) and upright (15 ± 11 mm Hg, P < .001) positions. Mean transcutaneous Pco2 increased only in the flexed position (3 ± 4 mm Hg, P < .005) and levels were still elevated five minutes after that position had been discontinued. The consistent decrease in transcutaneous Po2 was accompanied by a variable effect of positioning on V1 and there were no episodes of airway obstruction or apnea >10 seconds. Heart rate increased in each position whereas blood pressure remained unchanged. These data suggest that although hypoventilation may contribute to the observed decrease in transcutaneous Po2, ventilation/perfusion imbalance appears to be the major mechanism. As spinal taps performed in the widely accepted flexed position carry the greatest risk of potential morbidity, it is recommended that this position be modified with neck extension or that spinal taps be performed in the upright position.

Incidence of and Neurodevelopmental Outcomes After Late-Onset Meningitis Among Children Born Extremely Preterm

“…The performance of LP can be associated with hypoxemic episodes, and any infant sick enough to warrant evaluation for late-onset infection may be considered too unstable to tolerate the positioning for LP. 27 , 28 , 29 This may be especially true for infants supported with high-frequency oscillatory ventilation, the technicalities of which make changing infant position problematic. Frequently, CSF obtained from LP is contaminated with red blood cells, and cell counts can be challenging to interpret.…”

Impact of bundle implementation on the incidence of peri/intraventricular hemorrhage among preterm infants: a pre-post interventional study

“…Some studies have shown that during CSF collection in newborn infants, the arterial blood partial pressure of oxygen decreases and that of carbon dioxide increases. 20 , 29 These factors, together with the pain caused by the procedure, 30 might alter cerebral blood flow. A retrospective study that included 106,461 very low birth weight infants found an association between lumbar puncture for CSF collection in the first three days of life and occurrence of PIVH grades III/IV.…”

“…The bundle implemented within the first 72 hours of life among all the eligible infants consisted of the following procedures: 1) maintaining the infant in dorsal decubitus and neutral elevated head position; 14 , 15 , 17 2) avoidance of physical therapy maneuvers and aspiration of the tracheal cannula; 18 , 19 3) postponing cerebrospinal fluid (CSF) collection for sepsis work-up until after 72 hours of life; 14 , 20 5) assessment of daily weight only after the first 72 hours of life; and 6) reinforcement of minimal handling and environmental policies. 14 , 15 …”

The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Neonatal and Infant Spine

“…The knees may be flexed to the abdomen to allow adequate separation of the spinous processes and visualization of the spinal canal contents. Avoid overzealous and excessive flexing that could impede respiration 18 . An infant who has recently been fed will generally lie quietly during the examination.…”

“…Avoid overzealous and excessive flexing that could impede respiration. 18 An infant who has recently been fed will generally lie quietly during the examination. If preprocedural feeding is not possible, a pacifier dipped in glucose solution can be helpful in keeping an infant still, thereby optimizing the examination.…”