Avoid needless problems with lumbar punctures

Pain management is lacking

Of 353 children who had lumbar punctures performed at Children's Hospital at Montefiore in Bronx, NY, only 84 received some form of pain management before the procedure, according to a new study.1

"Our study highlighted the importance of all health care providers to advocate for adequate analgesia use for patients undergoing painful procedures, especially those patients that can't advocate for themselves," says Daniel Fein, MD, the study's lead author and a fellow in the hospital's Division of Pediatric Emergency Medicine.

Fein notes that there are many indications for a lumbar puncture, including infectious workups to rule out meningitis or encephalitis, and neurological workups to look for increased intracranial pressure to diagnose psuedotumor cerebri. He says that one helpful practice is identifying patients who potentially will have a lumbar puncture as early in the ED visit as possible. "This could potentially facilitate the early application of topical anesthetics such as EMLA [eutectic mixture of local anesthetic], which require time to achieve efficacy," says Fein.

Here are other problems that can occur with lumbar punctures:

• Spinal headache.

Patients might report a dull ache with a stiff neck and nausea, says Shannon Martin, RN, an ED charge nurse at St. Anthony's Medical Center in St. Louis, MO. "It has been reported that it is necessary to lay flat for one hour and as long as 12 hours, but there is no evidence to support this theory," he adds.2

Martin says that small-gauge, atraumatic needles might decrease the patient's risk of headache. "Reinsertion of the stylet before needle removal should occur," says Martin. "Patients do not require bed rest after the procedure."

• Cerebrospinal fluid leakage.

This leakage is caused by the needle puncture into the spinal area, which causes a small amount of fluid to leak into the muscle and depletes the normal level of cerebrospinal fluid, says Martin.

• Infection.

"This is always a concern with any procedure. Sterility is the key to decrease the infection rate," says Martin.

• Bleeding.

"A review of the patient's medical history and medication list is primary to any procedure," says Martin. "The use of blood-thinning medications may be contraindicated for the procedure. With any bleeding, firm pressure must be held."

• Anxiety.

Sedation should be considered for young children or anyone who might be unable to tolerate the procedure, says Fein.

Martin says that lorazepam and diazepam often are used to reduce the patient's anxiety and that understanding more about the procedure also is helpful. "Anxiety is a common problem and is as important as pain control to increase the chance of success and safety," he says.

References

  1. Fein D, Avner, J, Khine H. Pattern of pain management during lumbar puncture in children. Ped Emerg Care 2010;26:357-360.
  2. Thoennissen J, Herkner H, Lang W, et al. Does bed rest after cervical or lumbar puncture prevent headache? Can Med Assoc J 2001;165:1311-1316.