1 LUMBAR PUNCTURE LUMBAR PUNCTURE Department of Neurology Department of Neurology Faculty of Medicine of UNPAD Faculty of Medicine of UNPAD Hasan Sadikin Hospital Hasan Sadikin Hospital
Jan 19, 2016
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LUMBAR PUNCTURELUMBAR PUNCTURE
Department of NeurologyDepartment of NeurologyFaculty of Medicine of UNPADFaculty of Medicine of UNPAD
Hasan Sadikin Hospital Hasan Sadikin Hospital
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Lumbar PunctureLumbar Puncture
A procedure to collect cerebrospinal fluid A procedure to collect cerebrospinal fluid (CSF) that encircles the brain and spinal (CSF) that encircles the brain and spinal cordcord
Other sites that can be used to obtain Other sites that can be used to obtain CSF: CSF: below occipital tuberose below occipital tuberose sub occipital sub occipital
puncturepuncture babies: anterior fontanel babies: anterior fontanel
CSF|CSF|LPLP
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Lumbar PunctureLumbar Puncture
Aims:Aims:
Diagnostic of infection and inflammation in Diagnostic of infection and inflammation in the subarachnoid spacethe subarachnoid space Obtained by collecting sample for cellular, Obtained by collecting sample for cellular,
chemical, and bacteriological analyses of the chemical, and bacteriological analyses of the CSFCSF
Therapeutic:Therapeutic: chemotherapy for carcinomatosischemotherapy for carcinomatosis antibioticsantibiotics
Intrathecal anesthesiaIntrathecal anesthesia
CSF|CSF|LPLP
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Indication:Indication:
Diagnosis of CNS infection: meningitis, Diagnosis of CNS infection: meningitis, encephalitis, tertiary syphilis,encephalitis, tertiary syphilis,Diagnosis of meningeal carcinomatosis, Diagnosis of meningeal carcinomatosis, meningeal leukemia, staging of lymphoma meningeal leukemia, staging of lymphoma Follow up for therapy of meningitis Follow up for therapy of meningitis Treatment for pseudo tumor cerebri Treatment for pseudo tumor cerebri Evaluation of several diseases: dementia, Evaluation of several diseases: dementia, Guillain-Barre Syndrome Guillain-Barre Syndrome Ruling out subarachnoid bleedingRuling out subarachnoid bleeding
CSF|CSF|LPLP
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ContraindicationContraindication::
Infection at the site of punctureInfection at the site of puncture
History of anticoagulant useHistory of anticoagulant use
Presence of signs of increased intracranial Presence of signs of increased intracranial pressure pressure
Severe hemorrhagic diathesisSevere hemorrhagic diathesis
Proven intracranial mass (from Proven intracranial mass (from neuroimaging)neuroimaging)
CSF|CSF|LPLP
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TechniqueTechnique
Prepare the equipments needed for the procedureGreet the patient. Explain the LP procedure to the patient, its advantages and disadvantages.Ask his/her consentAsk the patient to lay on his left side of the body (left lateral decubitus). Place the patient near the edge of the bed.Flex the neck, trunk, hips, and knees; the patient’s body should be perpendicular to the bed
CSF|CSF|LPLP
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Technique (cont.)Technique (cont.)
Locate the site of puncture (L3 – L4) interspace in adult patient) by drawing an imaginary line between the highest points of the iliac crests (crista iliaca). The site is in the intersection of the imaginary line and vertebral axis
Wash your hands Put on a pair of sterile gloves
CSF|CSF|LPLP
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Technique (cont.)Technique (cont.)
Apply alcohol swab to the puncture site and surrounding area with circular movement, followed by applying povidone-iodine solution with the same manner
Wipe with alcohol to remove all traces of the antiseptic to prevent it from entering the subarachnoid space; and wipe it once more using a dry gauze
Cover the LP area with perforated drape
CSF|CSF|LPLP
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Technique (cont.)Technique (cont.)
Infiltrate the site of lumbar puncture with 2 mL of 2% lidocaine HCl for local anesthesia. Start with injecting up to 1 mL of lidocaine to the interspinous ligament and infiltrate the adjacent subcutaneous area with the remaining lidocaine. Wait several moments to let the anesthesia works
CSF|CSF|LPLP
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Technique (cont.)Technique (cont.)
Take a sterile spinal needle. Make sure that the needle is equipped with stylet, lock the stylet inside the needle, and then insert it slowly with the bevel faces up (parallel to the long axis of the body) until it enters the subarachnoid space
Verify that the needle is indeed in the subarachnoid space, then turn the needle counterclockwise to 9 o’clock position
CSF|CSF|LPLP
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Technique (cont.)Technique (cont.)
Withdraw the stylet
Collect the CSF in three sterile tubes:- Tube 1: 10 – 15 drops for cell count and
differentiation- Tube 2: up to 5 mL for bacteriological
workups- Tube 3: up to 2 mL for chemistry (protein,
glucose)
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Technique (cont.)Technique (cont.)
Reinsert the stylet, turn the needle back to 12 o’clock, and then withdraw the needle
Apply some pressure to the puncture site, and then cover it with sterile gauze soaked by povidone-iodine
Ask the patient to lay flat for at least 6 hours to prevent post-LP headache
Take off your gloves, wash your hands
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ComplicationComplication
HeadacheHeadache
BackacheBackache
Subdural HematomSubdural Hematomaa
InfectionInfection
CSCSFF leakage leakage
HerniationHerniation
CSF|CSF|LPLP
THANK YOUTHANK YOU
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