Lumbar drains and taps

Joe Hlavin PA-C

Lumbar drainsLumbar puncture

Not a big difference between the two▪ Same technique▪ Both take off CSF

The differences are the reasons▪ And results

The use of an implanted soft tube placed in the lumbar thecal sac for the purpose of continuously or intermittently draining CSF

Generally requires discussion and consent with the patient

Performed under sterile conditions but can be done at the bedside

Implications Adjunct to the treatment of post op or

traumatic CSF leaks secondary to dural opening or injury

Rhinorrhea – traumatic and surgically induced

Alternative CSF pathway if VPS is removed for infection

Reduce ICP during craniotomy Decrease ICP in TBI

Procedure Patient position▪ Lateral decubitus or sitting bent forward over tray▪ Practitioner preference and patient status

depends I use a lumbar puncture tray – has

everything I need Just need gloves and the ELD kit de jour EXPLAIN to patient what you are doing if MS

permits

Practitioner’s choice I prefer the lateral decubitus I palpate the iliac crest with index and

middle finger then straight across I place my thumb which will be L4-5

Pitfalls Older patients with stenosis – go higher Angle of attack - start midline, then go to

the right or left

See where L4-5 is relativeto the iliac crest

Must be intradural to get CSF

NOTE – Keep bevel of needle CEPHALAD

WHY?

Once I have CSF return I will Feed in the catheter NOTE – make sure that the bevel is

UP/CEPHELAD so the the catheter goes UP If you meet resistance, don’t worry – make

SMALL adjustments in depth and resist the urge to aim needle up – this will only bring the bevel more dorsal. Angle down to open the bevel to the canal

Run the catheter in until you reach 4 dots

Secure the drain after needle is removed NOTE – do not lose sight of the catheter

– they are sneaky and will start to come out

I use benzoin, or sticky stuff de jour, around the catheter entrance then an opsite dressing

2 -3 inch tape to run it up the back to the shoulder

Attach the Becker drain – leave closed until everyone is done “messing” with the patient

Then set the drain to 10 ml/hour or 80cc/8-hour shift NOTE – I like to use the one time drain

per shift to avoid the ICU staff from opening and forgetting.

Remember that this is a closed sterile system but would recommend Atbx while drain is in.

Actually placing the lumbar drain is only part of the care of the patient What is the information we can get?▪ CSF for culture▪ Pressure readings▪ A dry wound

How long do we leave it in?▪ What result(s) are we looking for?▪ When is the right time to remove?

Reviewing initial slides Refer to the approach and needle

placement▪ Approx. L4-5▪ Intradural▪ Look for CSF return

Diagnostic R/O SAH with neg CT▪ Xanthochromia

Meningitis – HA/Fever ▪ Protein, WBC, glucose

NPH – draining improves pt Psuedotumor Cerebri - pressure MS – IgG, Oligoclonal bands

Therapeutic (RARE) Periodic treatment of psuedotumor▪ Periodic visual impairment

Careful – CT first in impaired pt and know the coags

Thank you