Risk factors for unsuccessful lumbar puncture in children

Abstract

Background. This descriptive study provides the first information on an association between the use of sedation and a reduction in the prevalence of unsuccessful lumbar puncture (LP) in African children of all races. Objective. Our hypothesis was that children who do not receive any procedural sedation are more likely to have unsuccessful LPs. Methods. A cross-sectional observational study examined LPs performed from February to April 2013, including details of the procedure, sedation or analgesia used, and techniques. The setting was the Medical Emergency Unit at Red Cross War Memorial Children's Hospital, Cape Town, South Africa, and the participants all children aged 0-13 years who had an LP in the unit during the time period. Results. Of 350 children, 62.9% were <12 months of age, the median age being 4.8 months (interquartile range 1.5-21.7). The prevalence of unsuccessful (traumatic or dry) LP was 32.3% (113/350). Sedation was used in 107 children (30.6%) and was associated with a reduction in the likelihood of unsuccessful LP (p=0.002; risk ratio (RR) 0.5 (95% confidence interval (CI) 0.34-0.78)) except in those <3 months of age, where sedation did not significantly reduce the likelihood (p=0.56; RR 1.20 (95% CI 0.66-2.18)). Conclusions. Unsuccessful LP was common. Sedation was not routinely used, but the results suggest that it may be associated with a reduction in the rate of unsuccessful LP. Unsuccessful LP may lead to diagnostic uncertainty, prolonged hospitalisation and unnecessary antibiotic use. Whether a procedural sedation protocol would reduce the rate of unsuccessful LP requires further study.

Incidence of Traumatic Lumbar Punctures in Neonates and Infants

“…Depending on the criterion of TLP, the incidence of TLP was 1.5 to 2 times higher in neonates compared with infants. With the criterion of !500 erythrocytes/µL, the present 42.9% incidence of TLP agreed well with the incidences of 39.5 7 and 47.7% 13 neonatal and approximately 400 infant procedures, the sample sizes of the other studies were much smaller-53 neonatal and 167 infant procedures, 11 and 40 neonatal and 57 infant procedures. 8 These differences and possible selection bias are likely to explain these discordant age-specific incidences.…”

“…14 Early stylet removal techniques may improve the success rate of LP, but whether this approach reduces the incidence of TLP is not known. 6 10 11 24 So far, the existing evidence regarding the ability of various clinical approaches to reduce TLPs rests largely on observational evidence, excluding the utility of general anesthesia, deep sedation, and ultrasound-assisted LP. In this respect, the results of a recent large randomized controlled trial of over 1,000 neonates are expected to confirm whether the patient position or early stylet removal technique improves the success rate of neonatal LP and reduces the incidence of TLP.…”

“…These include sedation or anesthesia of the patient, experienced personnel, image guidance, patient position, size of the spinal needle, and stylet removal during the procedure. General anesthesia or deep sedation impedes the patient's movements, makes the provision of LP smoother, and improves the odds of success, 6,11 but at the expense of health risks that need to be weighed against the expected benefits case-by-case. This explains physicians' general reluctance to employ general anesthesia or deep sedation in neonatal and infant LPs.…”

“…14 Early stylet removal techniques may improve the success rate of LP, but whether this approach reduces the incidence of TLP is not known. 6,10,11,24 So far, the existing evidence regarding the ability of various clinical approaches to reduce TLPs rests largely on observational evidence, excluding the utility of general anesthesia, deep sedation, and ultrasound-assisted LP. In this respect, the results of a…”

Ultrasound‐guided “saline myelogram”: Confirmation of intrathecal drug delivery despite “dry tap” in infants for spinal anesthesia and spinal therapeutics

“…Previous case series on diagnostic lumbar punctures and spinal anesthetics in infants document comparatively high rates of traumatic or unsuccessful procedures; the latter is known as a “dry tap.” 1 Several studies have reported a first pass success rate of only around 60% 2 . The thecal sac in quite narrow in‐term and preterm newborns.…”