Prevent needless pain during lumbar punctures

Simple practices reduce difficulties

If lumbar punctures are not successful, there can be needless discomfort, antibiotic use, and hospitalization for your patient, says Lise E. Nigrovic, MD, MPH, and attending ED physician at Children's Hospital Boston.

Researchers looked at 1,459 lumbar punctures done in the ED at Children's Hospital in Boston and of these, 513 (35%) were traumatic or unsuccessful on the first attempt. Lack of local anesthetic use was one of the factors associated with the difficult cases.1

Both eutectic mixture of local anesthetic (EMLA) cream and injected lidocaine can be used for children undergoing lumbar punctures, says Nigrovic. "While lidocaine is usually injected at the time of the procedure, EMLA can be placed by nursing staff on the backs of children who are likely to undergo lumbar punctures," she notes. The youngest patients are at the highest risk for traumatic lumbar punctures, Nigrovic says.

At Children's Healthcare of Atlanta, ED nurses apply liposomal 4% lidocaine cream (LMX), a topical anesthetic product similar to EMLA, to the lumbar puncture site before physician puncture attempts, as part of the ED's standard protocol for septic work-up, says Marianne Hatfield, RN, BSN, system director of emergency services. [Click here for a copy of the ED's septic work-up for febrile infants.] "Our nurses are trained in the proper placement of the topical anesthetic on the lower spine during orientation. It is also reviewed annually during required competency training," she says. Here is what ED nurses do:

  • Identify patients that might require a work-up at triage.
  • Apply a topical anesthetic to potential peripheral intravenous access sites.
  • Apply topical anesthetic to the lumbar puncture site after the patient is in the treatment room.
  • Complete other procedures that are part of a septic work-up: first, catheterization for a urine culture, then peripheral intravenous line placement and blood specimen collection.
  • Notify the physician that the patient is ready for lumbar puncture."This allows the topical anesthetic to have taken effect," says Hatfield."The physician then injects lidocaine and completes the lumbar puncture."

In addition, nurses give infants a pacifier dipped in "Sweetease" — a sucrose solution that infants love to suck on, says Hatfield. "It helps to distract them from the uncomfortable position they must be placed in for optimal puncture success," she says.

In another study of 148 lumbar punctures, researchers found that the procedure was difficult in 47 patients (32%) and traumatic in 23 patients (16%). The percentage of patients that did not have a visible spine was significantly higher in the difficult and traumatic groups.2

The study shows that it may be possible to predict which patients will have difficult or traumatic lumbar punctures before performing the procedure, says Jonathan A. Edlow, MD, one of the study's authors and associate chief of the Department of Emergency Medicine at Beth Israel Deaconess Medical Center in Boston. Doing a simple bedside assessment of spine visibility and palpability may assist in planning your approach to a lumbar puncture, says Edlow.

To ensure that the patient is adequately prepared for the procedure, do the following:

  • Give adequate analgesia or anti-anxiety medications if necessary. "Ask the patient if their pain or anxiety is a problem. If the answer is yes, then suggest medications to the physician," says Edlow.
  • Ask the patient if they have any questions about the procedure, and either answer those or refer them to the physician. "Though this is really a pretty benign procedure, be sure to give the patient adequate psychological support," says Eldow.
  • Position the patient correctly. "Holding the patient as asked by the physician is very important to increase the likelihood of a successful tap," says Edlow.

References

1. Nigrovic LE, Kuppermann N, Neuman MI. Risk factors for traumatic or unsuccessful lumbar punctures in children. Ann Emerg Med 2007: 49:762-771.

2. Shah KH, McGillicuddy D, Spear J, et al. Predicting difficult and traumatic lumbar punctures. Am J Emerg Med 2007; 25:608-611.